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A  TEXT-BOOK  OF 

GYNECOLOGY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofgynecoOOgard 


A  TEXT-BOOK  OF 

GYNECOLOGY 


BY 


WILLIAM    SISSON   GARDNER,  M.D. 

PROFESSOR   OF    GYNECOLOGY,    COLLEGE    OF    PHYSICIANS    AND    SURGEONS 

BALTIMORE,    MD. 


WITH  ONE  HUNDRED  AND  THIRTY-EIGHT  ILLUSTRATIONS 

IN  TEXT 


NEW  YORK  AND  LONDON 
D.    APPLETON   AND   COMPANY 

1912 


Copyright,  1912,  by 
D.  APPLETON  AND  COMPANY 


PRINTED    IN    THE    UNITED    STATES    OF    AMERICA 


PREFACE 

In  preparing  this  volume  the  limited  time  of  the  over- 
crowded medical  student  has  been  taken  into  consideration. 
The  facts  have  been  stated  briefly  and  an  attempt  has  been 
made  to  put  them  clearly.  Many  subjects  that  are  given 
space  in  text-books  on  gynecology,  but  which  belong  to 
general  surgery,  have  been  omitted.  Many  rare  diseases 
are  treated  very  briefly.  The  greater  amount  of  space  is 
given  to  diseases  that  are  common  and  with  which  it  is 
essential  that  the  student  should  be  familiar.  It  is  believed 
that  enough  has  been  given  on  each  subject  to  constitute 
a  thorough  presentation  of  it. 

I  am  indebted  to  Mr.  Herman  Schapiro  for  the  photo- 
graphs of  the  gross  pathological  specimens  and  for  the 
photomicrographs.  These  gross  specimens,  and  the  slides 
from  which  the  photomicrographs  were  made,  are  a  part 
of  the  material  which  I  have  been  using  for  several  years 
in  teaching  diagnosis  and  living  gynecological  pathology. 
I  am  indebted  to  Mr.  W.  Starr  Gebhart,  Jr.,  and  to  Dr. 
J.  A.  Rippert  for  the  line  drawings.  Dr.  G.  Alvin  Strauss 
and  Dr.  A.  Samuels  gave  material  assistance  in  examining 
the  preliminary  copy  and  noting  omissions  of  fact. 

William  S.  Gardner. 

6  W.  Freston  Street, 

Baltimore,  Md. 


CONTENTS 


CHAPTER  I 

EXAMINATION   OF   THE    PATIENT 

Clinical  record  —  Abdominal  examination  —  Vaginal  examination 
Instruments  used  in  examination  —  Positions 


Pages 
1-10 


CHAPTER   II 

MENSTRUATION 

Normal  menstruation —  Precocious  menstruation  — Delayed  menstru- 
ation —  Vicarious  menstruation  —  Menopause  —  Disorders  of 
menstruation  :  Amenorrhea  ;  Menorrhagia  ;  Metrorrhagia  ;  Dys- 
menorrhea   


11-18 


CHAPTER  III 


DISEASES    OF    THE    VULVA 


Anatomy  —  Adhesions  of  the  labia  majora  —  Skin  infections  —  Gon- 
orrheal vulvitis  —  Follicular  vulvitis  —  Phlegmonous  vulvitis  — 
Diphtheritic  vulvitis — Catarrhal  vulvitis  —  Pruritus  —  Hyperes- 
thesia of  the  vulva  —  Chancre  —  Chancroid  —  Kraurosis  —  Vari- 
cocele —  Hematoma  —  Epithelioma  —  Elephantiasis  —  Inguinal 
hernia  —  Hydrocele  —  Fibroids  —  Venereal  warts  —  Injuries  to 
the  vulva  —  Infections  of  Bartholin's  glands  —  Abscess  of  the 
vulvo-vaginal  gland ;  Retention  cyst  of  the  vulvo-vaginal  gland  — 
Imperforate  hymen 


19-37 


CHAPTER   IV 

DISEASES    OF    THE    VAGINA 

Anatomy —  Gonorrheal  vaginitis  —  Follicular  vaginitis —  Diphthe- 
ritic vaginitis  —  Aphthous  vaginitis — Tuberculosis  of  the  vagina 
—  Paravaginitis  —  Adhesive  vaginitis  —  Vaginitis  in  children  — 
Stenosis  of  the  vagina  —  Atresia  of  the  vagina  —  Vaginal  cysts  — 
Solid  tumors  of  the  vagina:  Fibroids;  Carcinoma;  Sarcoma; 
Chorio-epithelioma  —  Vaginismus  —  Dysparunia 


38-47 


CONTENTS 
CHAPTER  V 

INJURIES    TO    THE    PELVIC    FLOOR 


Pages 


Anatomy — Laceration  of   the   perineum  —  Rectocele — Cystocele — 

Recto-vaginal  fistula 48-67 

CHAPTER   VI 

URINARY    FISTULjE 

Varieties —  Etiology  —  Urethro-vaginal  fistula  —  Vesico-vaginal  fistula 
—  Vesico-utero-vaginal  fistula  —  Vesico-uterine  fistula  —  Uretero- 
vaginal  fistula 68-75 

CHAPTER   VII 

DISEASES    OF    THE    URETHRA    AND    BLADDER 

Urethral  caruncle —  Urethritis  —  Stricture  of  the  urethra—  Sub-ure- 
thral  abscess  —  Prolapse  of  the  urethra — Over-distention  of  the 
urethra  —  Urethrocele  —  Vesico-urethral  fissure  —  Exstrophy  of 
the  bladder  —  Cystitis  —  Vesical  calculus 76-89 

CHAPTER  VIII 

THE    UTERUS 

Anatomy  —  Malformations  of  the  uterus  —  Normal  position  of  the 

uterus 90-98 

CHAPTER  IX 

DISPLACEMENTS    OF    THE    UTERUS 

Forward  displacements:  Anteversion  ;  Anteflexion  —  Backward  dis- 
placements—  Downward  displacements  —  Lateral  displacements  — 
Upward  displacements  —  Inversion  of  the  uterus 99-119 

CHAPTER   X 

DISEASES    OF    THE    CERVIX 

Laceration  of  the  cervix  —  Endocervicitis  —  Erosion  of  the  cervix  — 
Cystic  degeneration  of  the  cervix  —  Stenosis  of  the  cervix  —  Atresia 
of  the  cervix — Hypertrophy  of  the  cervix 120-133 

CHAPTER  XI 

DISEASES    OF    THE    ENDOMETRIUM 

Endometritis  —  Tuberculous  endometritis  —  Hypertrophic  endome- 
trium—  Adenoma , 134-141 


CONTENTS  ix 

CHAPTER  XII 

CARCINOMA    OF    THE    UTERUS 

Pages 

Histology  —  Pathology  —  Etiology  —  Course  —  Symptoms  —  Diag- 
nosis —  Treatment 142-161 

CHAPTER  XIII 

SARCOMA,    CHORIO-EPITHELIOMA,   SUBINVOLUTION,  AND 
SUPERINVOLUTION    OF    THE    UTERUS 

Sarcoma  of  the  uterus  —  Chorio-epithelioma  —  Subinvolution  —  Su- 

perinvolution  of  the  uterus 162-167 

CHAPTER  XIV 

UTERINE    FIBROIDS 

Classification  according  to  position  — Pathology,  Secondary  patho- 
logical changes  —  Rate  of  growth  —  Period  of  growth  —  "Number 

—  Size  —  Complications  of  Fibroids  —  Fibroids  and  pregnancy  — 
Symptoms  —  Diagnosis  —  Treatment 168-187 

CHAPTER  XV 

DISEASES    OF   THE    FALLOPIAN    TUBES    AND    PELVIC    CELLULITIS 

Anatomy  —  Salpingitis  —  Tuberculous  salpingitis — Tumors  of  the 
Fallopian  tubes :   Fibromyoma ;   Papilloma  ;  Carcinoma ;   Sarcoma 

—  Pelvic  cellulitis 188-209 

CHAPTER   XVI 

EXTRAUTERINE    PREGNANCY 

Etiology  —  Pathology  —  Symptoms — Diagnosis  —  Treatment.     .     .     210-217 

CHAPTER   XVII 

DISEASE    OF    THE    OVARIES 

Anatomy —  Perioophoritis  —  Oophoritis  —  Cystic  ovaries  —  Hema- 
toma of  the  ovary — Cirrhosis  of  the  ovary — Hypertrophy  of  the 
ovary  —  Prolapsed  ovaries 218-226 

CHAPTER   XVIII 

OVARIAN    CYSTS 

Pathology  —  Pedicle —  Rate  of  growth  —  Symptoms  —  Diagnosis 


Differential  diagnosis  —  Complications  —  Prognosis  —  Treatment 


.)..- 


CONTENTS 


CHAPTER   XIX 

SOLID    OVARIAN    TUMORS  :      PAROVARIAN    CYSTS,   TUMORS    OF 
THE    BROAD    LIGAMENTS 

Pages 
Solid  tumors  of  the  ovary :  Fibromata ;  Papillomata ;  Carcinomata  ; 

Sarcomata — Parovarian  cysts  —  Solid  tumors  of  the  broad  liga- 
ment —  Varicocele  of  the  broad  ligament 245-251 

CHAPTER   XX 

TECHNIQUE 

Abdominal  operations  :  Place  of  operation;  Time  of  operation  ;  Prep- 
aration of  the  patient ;  Preparation  of  instruments,  etc. ;  Prepara- 
tion of  the  operator  and  assistants ;  Anesthesia ;  Position  of  the 
patient ;  Incision  ;  Drainage  ;  Closure  of  the  abdominal  wound  ; 
Dressing  of  wound  —  Vaginal  operations  :  Preparation  ;  Posterior 
vaginal  section  ;  Anterior  vaginal  section  ;  Dilatation  of  the  cervix  ; 
Curettage  —  Local  treatment :  Douches,  Tampons,  Applications    .     252-263 

CHAPTER   XXI 

POST-OPERATIVE    COMPLICATIONS 

Shock  —  Hemorrhage  —  Vomiting  —  Distended  intestines  —  Infection 

of  the  abdominal  wound  —  Fecal  fistulse  —  Hernia    .     .     .     .     .     264-267 

CHAPTER   XXII 

POST-OPERATIVE    TREATMENT 

Abdominal  operations :  Position  of  the  patient ;  Diet ;  Removal  of 
stitches  ;  Time  in  bed  —  Vaginal  operations  :  Repair  of  vaginal 
outlet ;  Curettement ;  Vaginal  celiotomy 268-271 

INDEX 275-286 


LIST  OF  ILLUSTRATIONS 


Figure 


Page 

1.  Bimanual  examination 7 

2.  External  genitals *9 


QO 


3.  Follicular  vulvitis 

4.  Epithelioma  of  the  vulva 29 

5.  Epithelioma  of  the  vulva.     (Photomicrograph) 30 

6.  Elephantiasis  of  the  vulva 31 

7.  Elephantiasis.     (Photomicrograph) 32 

8.  Venereal  warts "3 

9.  Venereal  warts.     (Photomicrograph) 34 

10.  Abscess  of  Bartholin's  gland 36 

11.  Normal  vaginal  epithelium.     (Photomicrograph) 39 

12.  Vaginal  cysts 45 

13.  Relaxed  vaginal  outlet 49 

14.  Complete  tear  of  the  perineum 49 

15.  Flap-splitting  operation  for  laceration  of  the  perineum.     First  step  .  53 

16.  Flap-splitting  operation.     Second  step 54 

17.  Flap-splitting  operation.     Third  step 55 

18.  Flap-splitting  operation.     Fourth  step 56 

19.  Emmet's  operation  for  laceration  of  the  perineum.     First  step  ...  57 

20.  Emmet's  operation.     Second  step 58 

21.  Emmet's  operation.     Third  step 59 

22.  Hegar's  operation  for  laceration  of  the  perineum 60 

23.  Operation  for  repair  of  the  sphincter  ani.     First  step 61 

24.  Operation  for  repair  of  the  sphincter  ani.     Second  step 62 

25.  Cystocele  and  rectocele 63 

26.  Thickened  vaginal  epithelium.     (Photomicrograph) 64 

27.  Repair  of  cystocele.     First  step 65 

28.  Repair  of  cystocele.     Second  step 65 

29.  Repair  of  cystocele.     Third  step 66 

30.  Repair  of  cystocele.     Fourth  step 66 

31.  Diagram  showing  location  of  urinary  fistula; 69 

32.  Repair  of  vesico-vaginal  fistula.     First  step 72 

33.  Repair  of  vesico-vaginal  fistula.     Second  step 73 

34.  Urethral  caruncle 76 

35.  Urethral  caruncle.     (Photomicrograph) 77 

36.  Post-menstrual  endometrium.     (Photomicrograph) 91 


xii  LIST    OF    ILLUSTRATIONS 

Figure  Page 

37.  Pie-menstrual  endometrium.     (Photomicrograph) 92 

38.  Normal  cervical  glands.     (Photomicrograph) 93 

39.  Blood  supply  to  the  uterus 94 

40.  Lymphatics  of  the  uterus 95 

41.  Normal  position  of  the  uterus     .     . 97 

42.  Anteflexion  of  the  uterus 100 

43.  Retroversion  of  the  uterus 102 

44.  Retroflexion  of  the  uterus 103 

45.  Manual  replacement  of  retrodisplaced  uterus.     First  step    .     .     .     .  104 

46.  Manual  replacement  of  retrodisplaced  uterus.     Second  step     .     .     .  105 

47.  Manual  replacement  of  retrodisplaced  uterus.     Third  step  ....  106 

48.  A  pessary  in  position 107 

49.  Round  ligament  suspension  of  the  uterus 109 

50.  Ventral  suspension 110 

51.  Prolapse  of  the  uterus Ill 

52.  Thickened  epithelium  on  a  prolapsed  cervix.     (Photomicrograph)    .  112 

53.  Operation  for  prolapse  of  the  uterus.     First  step 114 

54.  Operation  for  prolapse  of  the  uterus.     Second  step 115 

55.  Laceration  of  the  cervix 122 

56.  Repair  of  laceration  of  the  cervix 123 

57.  Amputation  of  the  cervix.     First  step 123 

58.  Amputation  of  the  cervix.     Second  step 124 

59.  Amputation  of  the  cervix.     Third  step 124 

60.  Amputation  of  the  cervix.     Fourth  step 125 

61.  Amputation  of  the  cervix.     Fifth  step 126 

62.  Erosion  of  the  cervix 128 

63.  Erosion  of  the  cervix.     (Photomicrograph) 129 

64.  Cystic  degeneration  of  the  cervix 130 

65.  Endometritis.     (Photomicrograph) 135 

66.  Endometritis.      (Photomicrograph) 136 

67.  Endometritis.     (Photomicrograph) 137 

68.  Tuberculous  endometritis.     (Photomicrograph) 138 

69.  Adenoma.     (Photomicrograph) 141 

70.  Epithelioma  of  the  cervix 142 

71.  Epithelioma  of  the  cervix 143 

72.  Epithelioma  of  the  cervix.     (Photomicrograph) 144 

73.  Epithelioma  of  the  cervix.     (Photomicrograph) 145 

74.  Epithelioma  of  the  cervix.     (Photomicrograph) 146 

75.  Epithelioma  of  the  cervix.     (Photomicrograph) 147 

76.  Adeno-carcinoma  of  the  cervix.     (Photomicrograph) 118 

77.  Adeno-carcinoma  of  the  body  of  the  uterus 149 

78.  Adeno-carcinoma  of  the  body  of  the  uterus.     (Photomicrograph)      .  150 

79.  Vaginal  hysterectomy.     First  step 157 

80.  Vaginal  hysterectomy.     Second  step 157 

81.  Vaginal  hysterectomy.     Third  step 158 


LIST    OF    ILLUSTKATIONS  xiii 

Figure  Page 

82.  Vaginal  hysterectomy.     Fourth  step 158 

83.  Chorionic  villi.     (Photomicrograph) 164 

84.  Chorio-epithelioma.     (Photomicrograph) 165 

85.  Multiple  fibroids 168 

86.  Submucous  fibroid 169 

87.  Fibroid  polypus 170 

88.  Subperitoneal  fibroid 171 

89.  Fibromyoma.     (Photomicrograph) 172 

90.  Adeno-fibromyoma.     (Photomicrograph) 173 

91.  Fibroid  undergoing  cystic  degeneration 174 

92.  Fibro  sarcoma.     (Photomicrograph) 175 

93.  Outline  of  abdomen  containing  a  large  fibroid 180 

94.  Supravaginal  hysterectomy.     First  step 184 

95.  Supravaginal  hysterectomy.     Second  step 185 

96.  Supravaginal  hysterectomy.     Third  step 186 

97.  Myomectomy 187 

98.  Uterine  end  of  Fallopian  tube.     (Photomicrograph) 1S9 

99.  Middle  of  Fallopian  tube.     (Photomicrograph)     .......  190 

100.  Fimbriated  extremity  of  Fallopian  tube.     (Photomicrograph)     .     .  19i 

101.  Salpingitis 192 

102.  Purulent  salpingitis.     (Photomicrograph) 192 

103.  Interstitial  salpingitis.     (Photomicrograph) 194 

104.  Hydrosalpinx 195 

105.  Hydrosalpinx.     (Photomicrograph) 196 

106.  Tubo-ovarian  abscess 197 

107.  Posterior  vaginal  section.     First  step 198 

108.  Posterior  vaginal  section.     Second  step 199 

109.  Removal  of  infected  tube 200 

110.  Removal  of  infected  tube  and  ovary 201 

111.  Posterior  vaginal  drain 203 

112.  Tuberculous  salpingitis 205 

113.  Tuberculous  salpingitis.     (Photomicrograph) 206 

114.  Diagram  showing  various  locations  of  extrauterine  pregnancy  in  the 

tube 211 

115.  Extrauterine  pregnancy 212 

116.  Tubal  abortion 213 

117.  Cortex  of  a  normal  ovary.     (Photomicrograph)    .......  219 

IIS.     Corpus  luteum.     (Photomicrograph) 220 

119.  Infected  ovary.     (Photomicrograph) 221 

120.  Operation  for  prolapsed  ovary 226 

121.  Multilocular  ovarian  cyst 228 

122.  Wall  of  multilocular  ovarian  cyst.     (Photomicrograph)      ....  229 

123.  Papillomatous  ovarian  cyst 230 

124.  Wall  of  papillomatous  ovarian  cyst.     (Photomicrograph)-     •     ■     •  23] 

125.  Ovarian  dermoid 232 


xiv  LIST    OF    ILLUSTRATIONS 

Figure  Page 

126.  Outline  of  abdomen  containing  an  ovarian  tumor 234 

127.  Outline  of  abdomen  with  ascites 236 

128.  Carcinoma  of  the  ovary  developing  from  papillomatous  cyst.     (Pho- 

tomicrograph)       239 

129.  Carcinoma  of  the  ovary  developing  from  an  adeno-cystoua.     (Pho- 

tomicrograph)       240 

130.  Sarcoma  of  the  ovary 241 

131.  Ovarian  fibroid 245 

132.  Solid  ovarian  carcinoma 246 

133.  Solid  ovarian  carcinoma.     (Photomicrograph) 247 

134.  The  parovarium 248 

135.  Parovarian  cyst 249 

136.  Variocele  of  the  broad  ligament 250 

137.  Closure  of  abdominal  wound 257 

138.  Dressing  of  abdominal  wound 258 


A  TEXT-BOOK  OF  GYNECOLOGY 

CHAPTER   I 

EXAMINATION    OF    THE    PATIENT 

Clinical  Record.  —  Too  much  stress  cannot  be  laid  upon 
the  necessity  of  taking  a  careful  clinical  record  of  each 
patient.  The  record  should  include  a  history  of  the 
patient's  symptoms  as  given  by  her  in  reply  to  certain 
routine  inquiries  and  to  additional  questions  asked  to 
develop  fully  any  particular  complaint  that  may  be  noted. 
The  patient  should  then  state  in  her  own  way  any  further 
facts  that  have  a  bearing  upon  her  condition.  The  record 
must  be  brief  but  must  cover  fully  a  few  essential  points. 
There  is  rarely  any  occasion  to  go  into  the  family  history. 
The  more  important  points  to  be  covered  in  the  record  are 
indicated  in  the  following  outline. 

Date.  Name.  Age. 

Besidence.  By  whom  referred. 

Appetite.  Bowels.  Defecation. 

Micturition. 

Previous  illnesses  and  operations. 

Gonorrhea.  Syphilis. 

Pregnancies. 

Menses. 

General  complaints. 

Physical  examination. 

The  name  of  the  patient  is  wanted  as  a  matter  of 
identification. 

1 


2  EXAMINATION    OF    THE    PATIENT 

The  age  is  taken  because  it  has  a  direct  bearing  on  the 
sum  of  probabilities  that  make  up  the  diagnosis,  since  some 
diseases  are  much  more  common  at  certain  periods  of  life 
than  at  others. 

The  record  of  the  eesidence  is  kept  principally  as  a  part 
of  the  identification,  but  it  often  will  help  directly  by  throw- 
ing light  on  the  social  status  of  the  patient. 

Inquiry  into  the  condition  of  the  appetite  and  bowels 
should  be  made  because,  no  matter  what  the  local  condition 
is,  the  nutrition  of  the  patient  is  always  a  matter  of  im- 
portance and  must  be  looked  after. 

It  should  be  ascertained  whether  defecation  is  painful 
or  not;  if  it  is  painful,  whether  the  pain  is  present  only 
during  defecation  or  continues  for  some  time  afterwards 
and  how  long  the  symptom  has  been  present. 

In  reference  to  micturition,  it  is  important  to  know 
whether  it  is  too  frequent  or  painful,  or  both,  and  if  so, 
how  long  these  symptoms  have  been  present. 

In  recording  the  previous  illnesses,  it  is  of  no  advan- 
tage to  go  into  the  history  of  the  diseases  of  childhood, 
or  even  those  of  later  life,  except  those  illnesses  that  had 
some  predominant  pelvic  or  abdominal  symptoms.  The 
most  important  of  these  are  the  infections  after  labors  or 
after  miscarriages.  Unfortunately  the  history  that  most 
patients  give  of  previous  operations  is  very  vague,  but 
in  cases  where  abdominal  operations  have  been  performed 
it  is  of  great  assistance  to  know  accurately  what  has  been 
done. 

As  a  rule  no  valuable  information  is  obtained  by  asking 
directly  if  the  patient  has  had  gonorrhea  or  syphilis.  It 
is  much  better  to  make  inquiry  as  to  the  history  of  the 
symptoms  that  may  have  been  due  to  these  diseases.  If 
the  patient  has  had  gonorrhea,  there  will  usually  be  a 
history  of  a  profuse  vaginal  discharge   associated  with 


ABDOMINAL    EXAMINATION  3 

burning  micturition,  the  date  of  which  can  usually  be  fixed. 
If  she  has  had  syphilis,  there  will  usually  be  a  history  of 
a  skin  eruption,  falling  hair,  or  repeated  sore  throat. 

It  is  hardly  necessary  to  go  into  the  history  in  detail 
of  each  one  of  the  patient's  pregnancies.  The  number  of 
labors  at  full  term  and  the  number  of  miscarriages  should 
be  noted,  and  what  is  of  great  importance  is  to  know 
whether  the  last  pregnancy  ended  as  a  full  term  labor  or 
as  a  miscarriage,  the  date  of  termination,  and  whether  it 
was  followed  by  any  sjrmptoms  of  infection. 

In  noting  the  menstrual  history  the  first  point  is  the 
date  of  the  last  period.  If  there  has  been  anything 
irregular  about  this  last  period,  then  the  dates  of  two  or 
three  previous  periods  should  be  noted.  Never  accept  the 
patient's  statement  that  she  is  always  regular;  get  the 
exact  dates.  Note  the  frequency,  duration,  and  relative 
quantity  of  blood  lost.  If  pain  is  present  during  the 
period,  determine  what  the  time  relation  is  between  the 
pain  and  the  flow,  what  the  character  of  the  pain  is,  and 
how  long  the  patient  has  suffered  from  it. 

When  these  points  have  been  noted,  the  patient  should  be 
asked  to  state  her  definite  complaints.  The  location  and 
character  of  any  pain  and  the  length  of  time  she  has  suf- 
fered from  it  should  be  recorded  in  detail. 

Abdominal  Examination.  —  In  beginning  the  physical  ex- 
amination, it  is  best  to  start  with  the  examination  of  the 
abdomen.  The  bladder  and  rectum  should  be  emptied  and 
the  patient  put  in  the  dorsal  position  with  the  limbs  ex- 
tended. All  coverings  between  the  ensiform  appendix  and 
the  symphysis  should  be  removed. 

Inspection,  palpation,  percussion,  and  auscultation  are 
all  employed. 

Inspection.  —  By  inspection  the  size  and  general  eon- 
tour  of  the  abdomen  is  noted.    "When  there  is  an  enlarge- 


4  EXAMINATION    OF    THE    PATIENT 

ment,  the  shape,  the  point  of  greatest  prominence,  and  the 
extent  of  the  movements  of  the  abdominal  wall  during 
respiration  are  noted.  Striae  indicating  previous  disten- 
tions, pigmentation,  and  enlarged  veins  should  be  looked 
for.  In  pregnancy  the  fetal  movements  can  often  be  seen. 
Cicatrices,  the  result  of  previous  operations,  should  be 
noted. 

Palpatio^.  —  By  palpation,  tumors,  displaced  organs, 
points  of  tenderness,  and  areas  of  muscular  rigidity  are 
discovered.  The  hands  of  the  examiner  should  be  warm 
and  he  should  proceed  slowly  and  gently,  beginning  by 
preference  over  that  portion  of  the  abdomen  where  nothing 
abnormal  is  likely  to  be  found.  If  this  is  done,  by  the 
time  the  portion  of  the  abdomen  is  approached  which  is 
suspected  to  be  abnormal  it  will  be  found  that  the  patient's 
timidity,  and  much  of  the  associated  muscular  rigidity,  will 
have  disappeared  and  the  examination  can  be  made  much 
more  easily. 

After  going  over  the  abdomen  in  a  general  way  special 
attention  should  be  directed  to  the  regions  of  the  appendix, 
the  gall-bladder,  the  kidneys,  and  the  ovaries.  The  most 
common  location  of  the  appendix  is  just  below  the  middle 
of  a  line  extending  from  the  umbilicus  to  the  anterior 
superior  spine  of  the  right  ilium.  The  common  signs  of 
disease  of  the  appendix  are  tenderness,  elicited  by  deep 
pressure  and  rigidity  of  the  muscles  over  this  area.  In  ex- 
ceptional cases  a  mass  can  be  palpated.  Disease  of  the 
gall-bladder  is  indicated  by  tenderness  and  muscular  rigid- 
ity over  its  region,  and  particularly  by  the  inability  of  the 
patient  to  take  a  full  breath  when  the  fingers  are  pressed 
firmly  under  the  edge  of  the  ribs  just  to  the  right  of  the 
median  line.  The  thickness  and  tension  of  the  abdominal 
walls  should  be  noted. 

Palpation  is  very  much  facilitated  if  the  patient  is  in- 


VAGINAL    EXAMINATION  5 

structed  to  breathe  deeply.  On  expiration  the  abdominal 
wall  relaxes  and  the  deeper  structures  in  the  abdomen  can 
be  palpated  without  making  undue  pressure.  If  a  tumor 
is  present,  some  idea  of  its  size,  origin,  mobility,  and  density 
can  be  made  out.  Fluctuation  can  be  felt  in  cystic  tumors, 
but  the  wave  produced  by  tapping  the  tumor  on  one  side 
while  one  hand  is  held  against  the  opposite  side  can  be  felt 
clearly  only  in  exceptional  cases.  The  value  of  this  sign 
has  been  exaggerated.  The  beginner  frequently  confuses 
the  true  fluctuation  wave  with  the  impulse  transmitted  by 
the  abdominal  wall. 

Percussion.  —  By  percussion  the  tympanitic  and  dull 
areas  are  mapped  out  and  their  relation  to  each  other 
and  to  any  palpable  tumor  are  noted.  It  is  very  important 
to  observe  whether  the  relation  of  these  areas  to  each  other 
change  with  the  change  of  the  position  of  the  patient. 

Auscultation.  —  The  most  important  sign  elicited  by 
auscultation  is  the  presence  or  absence  of  the  fetal  heart 
sounds. 

Vaginal  Examination.  —  "When  the  abdominal  examina- 
tion is  completed  the  next  step  is  the  examination  of  the 
external  genitals  and  the  pelvic  contents  by  way  of  the 
vagina.  This  is  done  by  inspection,  the  simple  vaginal 
touch,  and  by  the  bimanual  examination.  Before  attempt- 
ing a  vaginal  examination  the  patient  should  be  put  in  the 
dorsal  position  with  the  legs  flexed  and  separated,  but 
the  thighs  must  not  be  pressed  upon  the  abdomen.  A 
simple  way  to  get  a  good  position  is  to  flex  and  separate 
the  knees  but  keep  the  feet  on  a  level  with  the  back.  The 
bladder  must  be  empty. 

Inspection.  —  Practically  all  the  ordinary  diseases  of 
the  vulva  can  be  diagnosed  by  inspection.  By  separating  the 
labia  any  pathological  condition  of  the  vestibule  and  vagi- 
nal orifice  is  exposed  and  the  condition  of  the  perineum 


6  EXAMINATION    OF    THE    PATIENT 

and  the  color  and  position  of  the  anterior  and  posterior 
vaginal  walls  near  the  outlet  are  noted. 

Simple  Vaginal.  Touch.  —  By  simple  vaginal  touch  is 
meant  the  examination  by  the  introduction  of  one  or  two 
fingers  into  the  vagina  and  the  palpation  of  the  vaginal 
walls  and  cervix  without  any  counter  pressure.  By  this 
method  pathological  conditions  of  the  vaginal  portion  of 
the  cervix,  of  the  vaginal  walls,  or  any  pelvic  growths  that 
displace  the  vaginal  walls,  can  be  detected. 

Bimanual  Examination.  —  One  or  two  fingers  are  intro- 
duced into  the  vagina  while  counter  pressure  is  made  over 
the  lower  segment  of  the  abdomen  by  the  other  hand.  The 
first  thing  to  ascertain  is  the  position  of  the  uterus.  "When 
the  uterus  is  in  the  normal  position,  if  the  fingers  in  the 
vagina  are  placed  under  the  cervix  and  then  elevated  the 
fundus  can  be  felt  by  the  external  hand  just  above  the 
symphysis  (Fig.  1).  The  fingers  in  the  vagina  can  then 
be  slipped  forward  and  the  body  of  the  uterus  grasped 
between  the  fingers  of  the  internal  and  external  hands. 
In  this  way  its  size,  shape,  and  consistence  can  be  deter- 
mined. When  the  body  of  the  uterus  is  not  found  in  the 
normal  position,  it  should  be  sought  for  first  posteriorly 
and  then  laterally.  The  broad  ligaments,  the  tubes,  and 
the  ovaries  are  then  palpated.  This  can  be  done  very 
readily  after  the  uterus  has  been  located  by  slipping  the 
fingers  of  both  hands,  between  which  the  uterus  is  lying, 
either  to  the  right  or  to  the  left.  By  this  movement  the 
broad  ligament  and  everything  attached  to  it  must  come 
between  the  opposed  fingers. 

Complete  anesthesia  facilitates  all  bimanual  exami- 
nations and  is  absolutely  essential  in  many  cases.  The 
anesthetic  is  called  for  not  to  relieve  pain  produced  by 
the  examination,  but  to  secure  muscular  relaxation. 

Instruments  Used  in  Examination.  —  During  the  examina- 


INSTRUMENTS    USED    IN    EXAMINATION  7 

tion  of  a  patient  some  of  the  following  instruments  are 
frequently  needed :  catheter,  speculum,  tenaculum,  dressing 
forceps,  bullet  forceps,  dilator,  curette,  scissors,  needle, 
needle  holder,  and  suture  material. 

The  most  often  used  of  these  is  the  catheter.     When- 


Fig.  1.  —  Bimanual  Examination.  The  uterus  is  elevated  by  the  fingers 
under  the  cervix  until  the  fundus  can  be  felt  through  the  abdominal  wall  above 
the  pubes. 

ever  a  bimanual  examination  is  made  it  must  be  assured 
that  the  bladder  is  empty,  and  the  most  certain  way  to 
empty  it  is  to  pass  a  catheter. 

For  office  purposes  the  self-retaining,  trivalve,  Nott's 
speculum  is  one  of  the  most  satisfactory,  but  for  general 
usefulness  there  is  no  speculum  superior  to  the  perineal 


8  EXAMINATION    OF    THE    PATIENT 

retractor  of  Simon.  The  blades  of  this  speculum  are  made 
in  different  sizes,  and  the  blade  can  be  selected  which  is 
best  suited  to  the  case. 

It  is  often  necessary  to  draw  the  uterus  down,  and  when 
the  patient  is  not  under  an  anesthetic  this  should  be  done 
with  a  tenaculum.  If  it  is  introduced  well  into  the  cervical 
canal  a  good  hold  can  be  taken  without  giving  any  pain.  A 
simple  rule  for  the  use  of  the  tenaculum  without  giving 
the  patient  discomfort  is  to  avoid  mucous  membrane  that 
is  covered  with  squamous  epithelium. 

The  dressing  forceps  are  used  to  wipe  away  any  dis- 
charge and  clear  the  field. 

To  carry  the  examination  beyond  this  point  it  is  usually 
necessary  to  use  an  anesthetic.  The  patient  should  be  in 
the  lithotomy  position,  with  the  hips  drawn  well  over  the 
end  of  the  table.  Bullet  forceps  or  a  small  volsellum  are 
used  to  draw  the  uterus  down,  because  stronger  traction 
can  be  made  with  them  than  with  a  tenaculum,  and  it  is 
not  necessary  to  avoid  the  sensitive  areas. 

For  rapid  dilatation  of  the  cervix  some  pattern  of  the 
parallel-bar  dilator  is  preferable.  It  is  not  necessary  to 
make  a  very  wide  dilatation. 

The  curette  for  obtaining  material  for  microscopical  ex- 
amination from  the  cavity  of  the  uterus  or  the  cervix 
should  be  sharp,  and  so  made  that  the  edge  will  strike  at 
right  angles  to  the  surface  to  be  curetted.  The  material 
should  be  removed  in  as  large  fragments  as  possible. 

When  a  piece  of  the  cervix  is  required,  a  small  triangular 
section  can  be  removed  with  scissors  and  the  wound  closed 
with  one  or  two  sutures. 

The  uterine  sound  is  purposely  omitted  from  the  list  of 
instruments  ordinarily  used  in  making  examinations,  for 
the  reason  that  the  small  amount  of  information  to  be 
obtained   from  it   is   more   than   counterbalanced   by   the 


POSITIONS  9 

harm  resulting  from  its  unskilful  use.  The  man  who 
cannot  make  a  diagnosis  of  pregnancy  at  the  eighth  week 
by  bimanual  examination  cannot  use  a  sound  with  reason- 
able safety.  The  man  who  can  make  a  diagnosis  of  preg- 
nancy at  the  eighth  week  very  rarely  has  occasion  to  resort 
to  the  sound. 

Before  operation  the  urine  should  be  examined  in  all 
cases.  It  is  also  well  to  make  a  blood  examination  as  a 
routine  measure ;  but  it  is  especially  indicated  if  the  patient 
has  a  temperature  above  normal  or  is  anemic. 

Positions.  —  For  examination  or  for  operation  the  patient 
may  be  placed  in  the  following  positions: 

First  Dorsal  Position.  —  In  this  position  the  patient  lies 
on  a  straight  table,  the  limbs  and  body  on  the  same  plane. 
The  patient  is  placed  in  this  position  in  making  routine 
abdominal  examinations  and  in  doing  many  abdominal 
operations. 

Second  Dorsal  Position.  —  In  this  position  the  hips  and 
back  of  the  patient  are  on  a  level  table.  The  knees  are 
flexed  and  separated.  The  feet  are  kept  on  the  same  level 
with  the  hips  and  back.  This  position  is  used  for  the 
examinations  of  the  external  genitals  and  in  bimanual 
examinations. 

Lithotomy  Position.  —  In  this  position  the  patient  lies 
on  the  back,  the  legs  are  flexed  on  the  thighs,  and  the 
thighs  upon  the  abdomen.  This  position  is  used  for  all 
vaginal  operations.  With  the  patient  in  the  same  position 
except  with  the  hips  very  much  elevated  the  cystoscope  is 
used. 

Trendelenburg  Position.  —  In  this  position  the  patient 
lies  on  the  back  with  the  limbs  extended.  The  pelvis  is 
elevated  while  the  knees  are  slightly  or  not  at  all  flexed. 
This  position  is  used  in  nearly  all  pelvic  operations  that 
are  done  through  the  abdominal  wall.    The  position  assists 


10  EXAMINATION    OF    THE    PATIENT 

in  keeping  the  intestines  out  of  the  way  and  in  exposing 
the  pelvic  .contents  to  the  view  of  the  operator. 

Sims  Position.  —  In  the  Sims,  or  left  lateral  position 
the  patient  lies  on  the  left  side  with  the  left  arm  drawn 
behind.  The  knees  are  flexed  and  the  right  knee  is  drawn 
a  little  forward  and  over  the  left  one.  Many  of  the  plastic 
operations  about  the  vagina  and  cervix  can  be  done  in  this 
position,  but  the  majority  of  operators  have  abandoned  it 
for  the  simpler  lithotomy  position. 

Knee-Chest  Position.  —  In  this  position  the  patient 
rests  with  the  chest  on  the  table.  The  knees  are  drawn 
up  under  her  with  the  thighs  kept  at  right  angles  to  the 
surface  of  the  table.  This  position  is  used  principally  for 
assisting  in  the  readjustment  of  retrodisplacements  of  the 
uterus,  to  temporarily  relieve  pelvic  congestion,  and  in  ex- 
ploration of  the  bladder. 


CHAPTER    II 

MENSTKUATION" 

Normal  Menstruation.  —  The  periodic  flow  from  the  mu- 
cous membrane  of  the  body  of  the  uterus,  called  the  menses, 
usually  makes  its  appearance  when  the  girl  is  from  thirteen 
to  fifteen  years  old.  The  flow  recurs  every  twenty-eight 
days,  and  ordinarily  continues  from  three  to  five  days. 
When  the  flow  lasts  less  than  three  days  it  is  usually  scanty 
in  quantity,  and  when  it  continues  more  than  five  days  there 
is  generally  some  pathological  condition  to  account  for  it. 

The  flow  commonly  begins  and  ends  with  a  flow  of  mucus 
without  blood.  The  larger  part  of  the  menstrual  discharge, 
as  it  escapes  from  the  mucous  membrane  of  the  uterus,  is 
a  mixture  of  blood  and  mucus;  but  in  addition  there  are 
some  small  round  cells  that  have  escaped  through  the  sur- 
face and  glandular  epithelium  and  some  epithelial  cells. 
When  the  blood  and  mucus  are  present  in  the  normal  pro- 
portion, the  discharge  will  not  coagulate;  but  when  there 
is  an  excessive  proportion  of  blood,  coagulation  takes  place. 
It  is  difficult  to  determine  the  quantity  of  blood  lost  at  each 
period,  but  it  is  estimated  that  the  average  amount  is 
about  four  ounces. 

As  the  time  of  the  flow  approaches,  the  breasts  become 
fuller  and  slightly  tender,  there  is  more  or  less  feeling  of 
general  malaise,  there  is  a  sense  of  weight  and  heaviness 
in  the  pelvis  due  to  congestion ;  but  under  normal  conditions 
there  is  no  pelvic  pain  of  any  moment. 

During  menstruation  there  is  no  material  loss  of  any 

11 


12  MENSTKUATION 

portion  of  the  endometrium.  The  blood  escapes  between 
the  epithelial  cells,  and  it  is  only  over  small  areas  that 
these  epithelial  cells  are  carried  away. 

The  exact  relation  of  ovulation  to  menstruation  is  not 
known.  The  changes  in  the  endometrium  during  the  men- 
strual cycle  are  described  in  the  section  on  the  anatomy 
of  the  uterus.  These  changes  in  the  endometrium  and  the 
menstrual  flow  are  in  all  probability  due  to  an  ovarian 
secretion. 

Precocious  Menstruation.  —  When  regular  menstruation 
begins  at  an  unusually  early  age,  it  is  known  as  precocious 
menstruation.  This  term  does  not  include  occasional  bloody 
discharges  that  are  usually  due  to  some  local  lesion,  nor  the 
slight  flow  from  infants  that  is  sometimes  observed  soon 
after  birth.  In  cases  of  precocious  menstruation  there  is 
a  premature  development  of  the  generative  organs. 

Delayed  Menstruation.  —  When  regular  menstruation  is 
not  established  until  long  after  the  usual  age,  it  is  called 
delayed  menstruation.  In  these  cases  there  is  usually  a 
failure  of  development  of  the  genital  organs  or  the  delay 
may  be  due  to  anemia. 

Vicarious  Menstruation.  —  A  periodic  flow  of  blood  from 
some  other  mucous  membrane  than  that  of  the  uterus  is 
known  as  vicarious  menstruation.  It  is  rarely  seen,  but 
when  it  does  occur  the  hemorrhage  comes  most  frequently 
from  the  nasal  mucous  membrane. 

MENOPAUSE 

The  end  of  the  child-bearing  period  of  a  woman's  life  is 
known  as  the  menopause,  climacteric,  or  change  of  life.  The 
most  important  phenomenon  of  this  period  is  the  cessation 
of  ovulation ;  but  the  most  obvious  indication  that  the  indi- 
vidual has  reached  the  menopause  is  the  disappearance  of 


MENOPAUSE  13 

the  menses.  In  exceptional  cases  ovulation  may  continue 
after  the  menses  have  failed  to  appear,  but  ordinarily  both 
cease  at  about  the  same  time.  The  menstrual  life  of  most 
women  covers  a  period  of  a  little  more  than  thirty  years. 
In  a  very  large  per  cent  of  cases  the  flow  ceases  to  recur 
about  the  age  of  forty-seven,  but  the  age  of  cessation  is 
subject  to  wide  variations.  The  menopause  may  be  estab- 
lished at  the  thirtieth  or  the  flow  may  continue  up  to  the 
fifty-seventh  year.  As  the  menopause  approaches,  the  flow 
usually  decreases  in  quantity  for  a  few  periods,  skips  an 
occasional  period  and  then  ceases.  During  the  period  of 
diminution  and  for  a  time  after  the  final  cessation  of  the 
menses,  many  women  have  flushes  of  heat  and  other  nervous 
phenomena;  but  the  establishment  of  the  menopause  is  a 
physiological  process,  and  many  grave  errors  in  diagnosis 
are  made  by  charging  up  to  "  change  of  life  "  too  many 
symptoms  of  which  women  of  forty-five  complain.  It  is  of 
especial  importance  to  remember  that  any  excessive  flow 
from  the  uterus,  bloody  or  otherwise,  about  the  time  of 
the  menopause  is  a  danger  signal  that  calls  for  immediate 
investigation.  Over  fifty  per  cent  of  women  who  begin  to 
bleed  from  the  uterus  after  the  establishment  of  the  meno- 
pause have  some  form  of  carcinoma  of  the  uterus. 

With  the  establishment  of  the  menopause  there  is  an 
associated  atrophic  process  in  the  genital  organs.  The 
ovaries  become  small  and  cirrhotic.  The  Fallopian  tubes 
decrease  in  size  and  the  folds  in  the  mucous  membrane 
partially  disappear.  The  uterus  decreases  in  size;  the 
atrophy  of  the  cervix  may  go  so  far  that  only  a  little 
dimple  is  felt  in  the  walls  of  the  vagina.  The  vagina 
decreases  in  calibre,  becoming  more  tubular  or  even  funnel- 
shaped.  The  folds  in  the  vaginal  mucous  membrane  dis- 
appear. The  labia  lose  their  deposits  of  fat  and  become 
little  more  than  folds  of  skin. 


l-±  MENSTRUATION 


DISORDERS    OF   MENSTRUATION 

The  disorders  of  menstruation  are  discussed  briefly  to 
impress  upon  the  student  that  they  are  only  symptoms  of 
underlying  pathological  conditions,  and  that  before  any 
treatment  is  instituted  the  cause  of  the  disorder  must  be 
discovered. 

Amenorrhea.  —  Amenorrhea  is  the  absence  of  the  menses 
during  that  period  of  life  when  a  woman  should  be  men- 
struating regularly.  A  peimary  amenorrhea  is  one  in 
which  the  menses  have  never  become  established.  A 
secondary  amenorrhea  is  one  in  which  the  menses  have 
ceased  after  they  have  become  established.  Primary  amen- 
orrhea is  due  to  a  failure  of  development  of  some  of  the 
reproductive  organs.  Secondary  amenorrhea  is  frequently 
due  to  the  anemia  of  chlorosis,  tuberculosis,  or  some  other 
disease  that  decreases  the  quantity  of  red  blood  cells. 
Destruction  of  the  ovaries  by  disease  or  their  removal  by 
operation  causes  a  cessation  of  menses.  Among  the  more 
remote  causes  are  change  of  climate  and  mental  strain. 
Some  very  obese  women  cease  to  menstruate  at  a  very  early 
age,  but  the  direct  relation  between  the  accumulation  of 
fat  and  the  amenorrhea  has  not  been  established.  Recent 
observations  indicate  that  in  these  cases  of  obesity  there  is 
a  deficient  secretion  of  the  pituitary  gland.  There  is  a  con- 
siderable number  of  cases  in  which  the  cause  of  cessation 
is  not  obvious.  In  primary  amenorrhea,  as  a  rule,  the 
menses  never  appear;  but  in  some  cases  the  patient  will 
menstruate  for  a  few  times,  usually  scantily  and  at  irregu- 
lar periods,  and  then  the  menses  will  cease.  In  secondary 
amenorrhea  there  is  usually  a  progressive  decrease  in 
the  quantity  of  flow  for  several  periods  before  complete 
cessation.     When   a   woman  who   is   apparently   in   good 


DISORDERS    OF    MENSTRUATION  15 

health  and  has  been  menstruating  regularly  up  to  a 
definite  time  suddenly  ceases  to  menstruate,  there  is  always 
a  strong  presumption  of  pregnancy.  In  any  case  in  which 
there  is  a  congenital  atresia  of  the  cervix  or  vagina  or  an 
imperforate  hymen,  the  menstruation  may  be  perfectly 
regular,  but  the  blood  does  not  escape  to  the  outside.  These 
patients  usually  come  to  the  physician  complaining  that 
they  do  not  menstruate. 

The  cessation  of  the  menses  during  pregnancy  and 
lactation  should  not  be  classed  as  amenorrhea. 

The  administration  of  so-called  emmenagogues  and 
"  uterine  tonics  "  is  not  only  unnecessary  and  useless  in 
amenorrhea,  but  by  centering  the  attention  of  the  physician 
and  patient  upon  a  symptom  instead  of  the  disease  is  posi- 
tively harmful. 

Uterine  Hemorrhage.  —  Uterine  hemorrhage  is  usually 
spoken  of  as  menorrhagia  or  metrorrhagia.  Menorrhagia 
is  an  excessive  flow  of  blood  from  the  uterus  at  the  time 
of  the  regular  menstrual  period.  Metrorrhagia  is  an  ex- 
cessive flow  of  blood  from  the  uterus  at  any  other  time 
than  the  regular  menstrual  period.  It  is  not  possible  to 
draw  a  hard  and  fast  distinction  between  the  two  varieties 
of  hemorrhage,  because  there  are  many  lesions  that  cause 
both  menorrhagia  and  metrorrhagia.  Menorrhagia  may  be 
caused  by  endometritis,  hypertrophic  endometrium,  retro- 
displacement  of  the  uterus,  sub-involution,  uterine  fibroids, 
salpingitis,  varicose  veins  in  the  broad  ligaments,  ovarian 
tumors,  or  excessive  ovarian  secretion.  Metrorrhagia  may 
be  caused  by  uterine  fibroids,  carcinoma  of  the  cervix  or 
body  of  the  uterus,  sclerosis  of  uterine  arteries,  adenoma 
of  the  uterus,  endometritis,  incomplete  miscarriage,  extra- 
uterine pregnancy,  uterine  moles,  chorio-epithelioma,  in- 
version of  the  uterus,  or  malignant  ovarian  tumors. 

The    uterine    hemorrhage    due    to    endometritis    usually 


16  MENSTRUATION 

manifests  itself  after  a  definite  infection  and  is  very  com- 
monly associated  with  salpingitis.  In  a  considerable  num- 
ber of  cases  during  the  first  menstrual  period  after  the 
tubes  have  become  infected  there  is  not  only  an  excessive 
flow  of  blood  but  large  clots  are  passed  associated  with  pain. 
The  symptoms  resemble  fairly  closely  the  symptoms  ordi- 
narily observed  during  a  miscarriage.  At  the  succeed- 
ing menstrual  periods  the  amount  of  blood  lost  usually 
decreases. 

A  hypertrophic  endometrium  may  cause  menorrhagia  or 
metrorrhagia  at  any  age,  but  most  frequently  about  the 
time  of  the  menopause.  It  is  one  of  three  most  common 
causes  of  excessive  uterine  bleeding  at  the  climacteric. 

Menorrhagia  is  more  frequently  associated  with  acquired 
retrodisplacements  than  with  the  congenital  form.  The 
history  shows  that  the  increased  flow  has  begun  relatively 
soon  after  the  last  labor,  that  the  daily  amount  of  blood 
lost  during  the  menstrual  period  may  be  only  slightly  in- 
creased but  the  period  is  usually  prolonged. 

The  hemorrhage  due  to  uterine  fibroids  usually  begins 
as  a  gradually  increasing  menorrhagia.  Later  the  flow  of 
blood  may  become  almost  continuous.  Carcinoma  of  the 
body  of  the  uterus  may  cause  in  the  beginning  a  menor- 
rhagia, but  in  most  instances  the  hemorrhage  due  to  car- 
cinoma has  little  or  no  relation  to  the  menstrual  period. 
Every  patient  who  bleeds  after  the  establishment  of  the 
menopause  should  be  suspected  of  having  uterine 
carcinoma. 

The  hemorrhage  due  to  incomplete  miscarriage  is  due 
to  a  partial  detachment  of  the  placenta.  Not  infrequently 
it  is  very  profuse.  In  extrauterine  pregnancy  there  is  a 
history  that  the  menstrual  period  has  been  delayed  a  few 
days  and  that  the  period  has  come  on  with  more  pain  than 
usual.     Following  this   there  is   a  continuous   dribble   of 


DISORDERS    OF    MENSTRUATION  17 

blood  from  the  uterus  that  may  go  on  for  days  or  weeks. 
The  hemorrhage  due  to  chorio- epithelioma  comes  on 
after  a  labor,  a  miscarriage,  or  the  expulsion  of  a  hydati- 
form  mole.  It  is  a  continuous,  fairly  profuse  flow  and 
recurs  promptly  after  curettage. 

Dysmenorrhea.  —  Dysmenorrhea  is  painful  menstruation. 
It  may  be  caused  by  endometritis,  retrodisplacement  of  the 
uterus,  salpingitis,  anteflexion  of  the  uterus,  cervical  ste- 
nosis, uterine  fibroids,  and  diseased  and  prolapsed  ovaries. 
In  three  hundred  cases  of  dysmenorrhea  examined  the  fre- 
quency of  these  lesions  was  in  the  order  in  which  they  are 
mentioned.  There  is  an  occasional  patient  who  has  pain 
at  the  menstrual  period  in  whom  no  gross  lesion  can  be 
found. 

One  of  the  most  characteristic  dysmenorrheas,  although 
by  no  means  the  most  frequent,  is  the  one  in  which  the  pain 
is  due  to  anteflexion  of  the  uterus  or  congenital  stenosis  of 
the  cervix.  These  patients  as  a  rule  give  a  history  of  hav- 
ing had  pain  with  each  period  from  the  time  they  first 
began  to  menstruate.  The  pain  begins  just  before  the  flow 
makes  its  appearance.  It  is  paroxysmal  and  very  severe. 
After  the  first  twenty-four  hours  the  pain  is  very  much 
diminished  and  gradually  passes  off.  In  the  intermenstrual 
period  these  patients  suffer  from  no  discomfort  whatever. 

There  is  nothing  characteristic  about  the  dysmenorrhea 
associated  with  retro  displacements.  It  is  only  an  exagger- 
ation of  the  more  or  less  constant  discomfort  from  which 
the  patient  suffers. 

The  dysmenorrhea  due  to  salpingitis  is  usually  worse  just 
before  the  flow  begins.  It  not  infrequently  disappears  en- 
tirely during  the  middle  period  of  the  flow  and  returns  for 
a  day  or  more  at  the  cessation  of  the  flow. 

The  pain  during  the  menstrual  cycle  associated  with 
diseased  or  prolapsed  ovaries  frequently  comes  on  a  week 


18  MENSTRUATION 

before  the  flow  and  continues  during  the  whole  period  and 
for  a  few  days  after  the  cessation  of  the  flow.  The  pelvic 
discomfort  in  these  cases  is  very  commonly  accompanied 
by  a  severe  occipital  headache. 

In  membranous  dysmenorrhea  a  thickened  endometrium 
is  cast  off  in  parts  or  as  a  whole  at  each  menstrual  period. 
This  thickening  of  the  endometrium  is  due  to  an  infection. 
The  pain  produced  by  the  efforts  of  the  uterus  to  expel 
the  endometrium  are  labor-like,  very  severe,  and  cease 
suddenly  when  the  membrane  escapes.  Membranous  dys- 
menorrhea is  sometimes  confused  with  early  miscarriage. 
Each  can  be  distinguished  by  a  microscopical  examination 
of  the  material  expelled.  The  thickened  endometrium  ex- 
pelled in  membranous  dysmenorrhea  shows  the  cell  changes 
due  to  infection,  while  the  material  expelled  after  a  mis- 
carriage will  show  either  chorionic  villi  or  decidual  cells, 
or  both. 


CHAPTER    III 

DISEASES    OF    THE    VULVA 

ANATOMY 

The  vulva  includes  the  labia  majora,  the  labia  minora, 
the  clitoris,  the  vestibule,  and  the  vulvo-vaginal  glands. 

Labia  Majora.  —  The  labia  majora  are  two  folds  of  skin 
on  either  side  of  the  vulvar  cleft.  The  outer  surface  of 
each  labium  is  pigmented  and  cov- 
ered with  hairs.  The  inner  surface 
which  lies  in  contact  with  the  oppo- 
site labium  is  smooth,  has  rudimen- 
tary hairs,  and  many  large  sebaceous 
follicles.  The  labia  are  continuous 
above  with  the  mons  veneris,  and 
meet  below  to  form  the  fourchette. 
The  structures  forming  the  labia  ma- 
jora resemble  those  of  the  scrotum. 
Each  labium  contains  a  well-defined 
encapsulated  subcutaneous  mass  of 
fat. 

Labia  Minora.  —  The  labia  minora, 
or  nymphae,  are  smaller  than  the 
labia  majora  and  have  neither  hairs 
nor  fat.  Above,  each  labium  divides 
into  two  small  folds,  one  of  which  unites  with  the  corre- 
sponding fold  of  the  opposite  labium  above  and  the  other 
below  the  clitoris.  Below  they  gradually  diminish  in  size 
and  terminate  opposite  the  middle  of  the  vaginal  orifice. 

19 


Fig.  2.  —  External  Gen- 
itals. 


20  DISEASES    OF    THE    VULVA 

Both  surfaces  are  smooth,  hairless,  and  studded  with  large 
sebaceous  .glands. 

Vestibule.  —  The  vestibule  is  a  triangular  space  bounded 
on  either  side  by  the  labia  minora  and  below  by  the  orifice 
of  the  vagina.  The  meatus  urinarius  is  near  its  middle. 
On  either  side  are  the  bulbs  of  the  vestibule. 

Clitoris.  —  The  clitoris  is  a  rudimentary  penile  appendage. 
It  is  erectile  and  highly  sensitive. 

Bartholin's  Glands.  —  The  vulvo-vaginal,  or  Bartholin's 
glands,  are  two  small  racemose  glands  situated  one  on  either 
side  at  the  level  of  the  middle  of  the  orifice  of  the  vagina. 
The  ducts  are  about  three-quarters  of  an  inch  in  length  and 
open  opposite  to  each  other  just  in  front  of  the  vaginal 
orifice. 

ADHESIONS    OF    THE    LABIA   MAJORA 

Adhesions  of  the  labia  majora  may  occur  as  a  congenital 
condition  or  as  the  result  of  an  inflammatory  process  which 
produces  erosion  of  the  epithelium.  Subsequently  the  de- 
nuded surfaces  on  the  borders  of  the  labia  adhere.  The 
condition  is  easily  recognized  by  inspection.  The  adherent 
borders  can  usually  be  separated  either  by  light-  traction, 
made  by  pressure  on  the  labia  on  either  side,  or  by  inserting 
a  probe  between  the  labia  near  the  meatus  where  they  are 
never  adherent  and  breaking  the  adhesions  from  above 
downward.  In  exceptional  cases  it  is  necessary  to  use  a 
knife  to  separate  the  labia.  After  the  adhesions  have  been 
broken  up  it  is  necessary  to  keep  the  raw  surfaces  sepa- 
rated from  each  other  by  a  light  gauze  pack  until  they  are 
healed  over. 

SKIN   INFECTIONS 

Herpes,  eczema,  erysipelas,  thrush,  furuncles,  and  other 
skin  affections  are  found  on  the  labia  majora;    but  the 


VULVITIS  21 

symptoms,  diagnosis,  and  treatment  are  exactly  the  same 
as  when  these  diseases  occur  on  other  parts  of  the  body. 

VULVITIS 

All  of  the  ordinary  forms  of  vulvitis  or  inflammation  of 
the  vulva  may  be  grouped  under  five  heads :  gonorrheal, 
follicular,  phlegmonous,  diphtheritic,  and  catarrhal. 

GONORRHEAL    VULVITIS 

Gonorrheal  vulvitis  is  an  inflammation  of  the  vulva  due 
to  a  gonococcus  infection.  It  is  usually  associated  with  a 
gonorrheal  urethritis  and  vaginitis. 

Symptoms.  —  The  disease  develops  rapidly.  There  is 
much  burning  and  pain  about  the  vulva.  The  associated 
urethritis  causes  painful  urination. 

Diagnosis.  —  By  inspection  it  is  noted  that  the  labia  are 
red,  swollen,  and  covered  with  a  purulent  discharge.  In 
the  acute  stage  abundance  of  gonococci  are  found  in  the 
discharge. 

Treatment.  —  If  the  labia  are  much  swollen  the  patient 
should  be  put  to  bed.  Saline  cathartics  should  be  admin- 
istered and  acetate  of  potassium  should  be  given  in  twenty- 
grain  doses  every  four  hours  to  alkalinize  the  urine.  Hot 
moist  applications  should  be  made  to  the  swollen  parts. 
When  the  most  acute  stage  is  passed  the  whole  of  the 
infected  area  should  be  painted  over  with  a  solution  of 
nitrate  of  silver  thirty  grains  to  the  ounce.  This  should 
be  followed  up  by  vaginal  douches  and  washes  of  any  of 
the  milder  astringents,  such  as  sulphate  of  zinc  one  grain 
to  the  ounce,  or  a  weak  solution  of  tannic  acid  or  alum. 
It  is  usually  not  necessary  to  make  more  than  one  or  two 
applications  of  the  nitrate  of  silver,  because  the  infection 
on  the  surface  as  a  rule  clears  up  promptly. 


22 


DISEASES    OF    THE    VULVA 


Follicular  Vulvitis 

Follicular  vulvitis  is  characterized  by  an  infection  of 
the  follicles  in  the  labia.    The  infected  points  show  a  red- 
dened elevated  area  with  a  white  center.    .There  is  very- 
little  discharge,  but  there  is  an  intense  itching  and  burning. 
Diagnosis.  —  This  disease  is  recognized  by  the  elevated 
reddened  areas,  from  the  center  of 
which  a  small  amount  of  pus  can  be 
expressed. 

Treatment.  —  An  application  of  a 
solution  of  nitrate  of  silver,  thirty 
grains  to  the  ounce,  over  the  whole 
infected  area  after  it  is  thoroughly 
cleansed  will  usually  control  the 
process.  In  exceptional  cases  it  is 
necessary  to  take  a  point  of  nitrate 
of  silver  and  cauterize  each  follicle 
separately. 


Phlegmonous  Vulvitis 


Fig.     3 

Vulvitis. 


Follicular 


Phlegmonous  vulvitis  is  a  strepto- 
coccus   infection    of   the    connective 
tissues  of  the  vulva.    The  organisms 
may  penetrate  the  surface  either  through  an  abrasion  or 
through  a  hair  follicle.     It  is  usually  unilateral. 

Symptoms.  —  There  is  a  local  and  general  rise  of  tempera- 
ture. There  is  quite  severe  pain,  which  is  increased  by 
pressure. 

Diagnosis.  —  The  infected  area  is  at  first  swollen,  smooth, 
bard,  dry,  and  of  a  dark  reddish  color.  After  suppuration 
begins  the  mass  softens  near  the  center. 

Treatment.  —  In  the  early  stages  of  the  disease  the  patient 


VULVITIS  23 

should  be  kept  in  bed,  and  hot  applications  used.  As  soon 
as  there  is  any  indication  of  the  formation  of  pus  a  free 
incision  should  be  made  and  drainage  established. 

Diphthekitic  Vulvitis 

In  diphtheritic  vulvitis  the  mucous  surfaces  of  the  vulva 
are  infected  by  the  Klebs-Loeffler  bacillus.  A  true  diph- 
theritic membrane  is  formed  in  which  the  micro-organisms 
are  found.  This  disease  should  not  be  confused  with  the 
so-called  diphtheritic  vaginitis  and  vulvitis  that  is  seen  in 
the  puerperium  as  a  result  of  a  streptococcus  infection. 

Diagnosis.  —  The  diagnosis  is  made  by  finding  the  Klebs- 
Loeffler  bacillus  on  the  mucous  membrane. 

Treatment.  —  Diphtheria  antitoxin  should  be  injected  in 
the  same  manner  as  it  would  be  for  a  diphtheritic  infection 
located  on  any  mucous  membrane. 

Catarrhal  Vulvitis 

Into  this  group,  which  we  call  catarrhal  vulvitis,  are 
placed  all  those  cases  that  are  due  to  the  irritation  of 
diabetic  urine  or  vaginal  discharges,  and  those  due  to  in- 
fections by  other  micro-organisms  than  those  already  men- 
tioned. The  symptoms  vary  from  those  that  are  due  to  a 
gonorrheal  infection,  to  those  due  to  the  mildest  form  of 
infection.  There  is  some  redness  about  the  vulva ;  usually 
very  little  swelling,  and  only  a  moderate  amount  of  dis- 
charge. Before  beginning  the  treatment  it  is  essential 
to  determine,  if  possible,  the  cause,  and  treat  the  cause  of 
the  condition  first.  The  local  treatment  consists  in  the 
use  of  washes  of  mild  astringents.  Occasionally  it  is  neces- 
sary to  make  a  local  application  of  a  solution  of  nitrate 
of  silver,  or  of  one  of  the  stronger  antiseptic  astringent 
preparations. 


24  DISEASES    OF    THE    VULVA 


PRURITUS 

Etiology.  —  Intense  itching  of  the  vulva,  or  pruritus 
vulvae,  is  a  symptom  that  may  be  due  to  a  lesion  of  the 
vulva,  to  a  lesion  at  some  distance  from  the  vulva,  or  it 
may  be  impossible  to  assign  any  local  cause  for  it.  The 
vulvar  lesions  include  follicular  vulvitis,  eczema,  herpes, 
urticaria,  trichiasis,  and  parasites.  The  extravulvar 
lesions  include  diabetes,  endometritis,  cancer  of  the  uterus, 
pregnancy,  seat-worms,  and  hemorrhoids.  There  are  a 
considerable  number  of  cases  due  to  a  neurosis.  Of  all 
these  causes  the  irritating  vaginal  discharge,  the  diabetic 
urine,  and  the  neurosis  are  the  most  important. 

The  acrid  vaginal  discharge  frequently  comes  from  a 
chronic  gonorrheal  endometritis.  The  quantity  of  the  dis- 
charge may  be  so  small  as  to  attract  little  attention,  but 
it  is  the  quality  rather  than  the  quantity  of  the  discharge 
that  gives  the  trouble. 

The  urine  of  all  patients  with  pruritus  should  be  ex- 
amined. A  very  large  portion  of  stout,  elderly  women  who 
have  pruritus  are  diabetics. 

The  neurotic  cases  can  usually  be  recognized  by  the  ab- 
sence of  all  local  assignable  causes  of  the  itchiDg,  by  the 
extension  of  the  affected  area  up  over  the  abdomen  and 
down  the  thighs,  and  by  other  indications  of  an  existing 
neurosis. 

In  all  cases  the  itching  is  worse  at  night  and  is  increased 
by  heat  and  exercise.  The  discomfort  at  times  becomes 
so  intolerable  that  the  patient,  in  attempting  to  get  relief, 
will  dig  the  finger  nails  into  the  tissues  producing  abra- 
sions that  become  infected.  The  region  of  the  vestibule 
and  the  labia  minora  are  the  parts  usually  affected  the 
most  severely.     The  constant  irritation  and  loss  of  sleep 


HYPERESTHESIA    OF    THE    ATULVA  25 

has  a  very  depressing  effect,  and  if  long  continued  the 
patient  may  become  a  mental  and  physical  wreck. 

Treatment.  —  When  the  pruritus  is  due  to  an  assignable 
local  lesion  the  treatment  should  be  directed  to  its  re- 
moval, but  in  the  meantime  something  must  be  done  for 
temporary  relief.  A  two  and  a  half  per  cent  carbolic  acid 
solution,  applied  by  saturating  a  cloth  with  it  and  applying 
it  to  the  vulva,  is  one  of  the  most  efficient  means  of  reducing 
the  discomfort  temporarily.  Dusting  the  parts  with  calo- 
mel or  bismuth  subnitrate,  and  the  local  application  of  weak 
solutions  of  acetate  of  lead,  alum,  zinc  sulphate,  corrosive 
sublimate,  an  infusion  of  tobacco,  or  ointments  that  are 
purely  protective,  that  carry  a  parasitacide,  or  that  are  a 
vehicle  for  a  local  anesthetic  such  as  carbolic  acid  or 
cocaine,  are  all  useful  for  securing  temporary  relief. 

When  the  pruritus  is  due  to  a  vaginal  discharge  the 
source  of  the  discharge  must  be  treated.  To  relieve  the 
vulva  temporarily  glycerin  tampons  that  change  the  char- 
acter of  the  discharge,  or  dry  tampons  that  protect  the 
vulva  from  the  discharge  are  both  useful.  Mild  alkaline 
vaginal  douches  and  the  internal  administration  of  potas- 
sium acetate  give  relief. 

When  sugar  is  found  in  the  urine,  the  patient  should  be 
treated  as  any  other  diabetic. 

The  treatment  of  the  neurotic  form  is  very  unsatisfac- 
tory. Some  relief  is  had  from  the  administration  of  bro- 
mids  and  the  use  of  the  local  remedies  already  mentioned. 

HYPERESTHESIA    OF    THE    VULVA 

Hyperesthesia  of  the  vulva  is  an  extreme  sensitiveness 
of  the  vulva  to  touch.  It  is  sometimes  due  to  local  in- 
fections, to  the  irritation  from  vaginal  discharges,  fissures, 
or  to  urethral  caruncle.    In  most  cases  of  the  severe  forms 


26  DISEASES    OF    THE    VULVA 

the  patient  is  suffering  from  a  neurosis  and  there  is  no  dis- 
tinguishable local  lesion. 

Treatment.  —  Any  local  source  of  irritation  should  be  re- 
moved. The  treatment  of  the  neurosis  is  tonics,  change 
of  scene,  and  outdoor  life. 

CHANCRE 

A  chancre  is  an  initial  lesion  of  syphilis.  It  is  due  to 
an  infection  by  the  Spirochete  pallida.  The  chancre  makes 
its  appearance  in  from  fourteen  to  twenty-one  days  after 
infection.  In  the  majority  of  instances  it  presents  the 
appearance  of  a  small  parchment-like  patch  on  the  vulva. 
It  gives  rise  to  no  discomfort.  If  the  lesion  is  on  the 
mucous  membrane,  there  is  a  small  ulcerating  area  and  the 
tissues  beneath  are  deeply  indurated.  The  small  parch- 
ment-like chancres  that  are  seen  on  the  skin  about  the  vulva 
are  apparently  so  insignificant  that  they  are  frequently 
overlooked.  The  discharge  from  the  chancre  is  very  scanty 
and  of  a  serous  character.  The  chancre  is  usually  a  single 
sore  and  not  autoinoculable.  The  inguinal  glands  enlarge 
but  rarely  suppurate.  Local  treatment  has  little  or  no  in- 
fluence upon  the  chancre.  The  patient  must  be  given  treat- 
ment for  syphilis. 

CHANCROID 

A  chancroid  is  an  excavating  ulcer  due  to  an  infection 
by  the  strepto-bacillus  described  by  Ducrey.  It  makes  its 
appearance  from  forty-eight  to  seventy-two  hours  after 
infection.  It  usually  begins  as  a  small  ulcer  on  the  mucous 
surface  of  the  vulva  and  enlarges  rapidly.  It  is  usually 
multiple.  It  destroys  very  rapidly  the  tissues  of  the  vulva; 
but  the  vagina  resists  the  infection.  The  connective  tissue 
beneath  the  vagina  is  often  destroyed  without  affecting  the 


VARICOCELE  27 

mucous  membrane.  Its  borders  are  sharply  defined  and  not 
indurated.  It  gives  rise  to  a  profuse  purulent  discharge.  It 
is  a  local  infection  and  is  autoinoculable.  The  inguinal 
glands  enlarge  and  have  a  tendency  to  suppurate. 

Treatment.  —  The  surface  of  the  ulcer  should  be  cleansed 
and  painted  over  with  pure  carbolic  acid.  This  acts  as  a 
local  anesthetic.  The  same  area  is  then  painted  immedi- 
ately with  pure  nitric  acid.  One  treatment  of  this  sort 
usually  destroys  the  micro-organisms  and  converts  the 
chancroid  into  an  ordinary  ulcer.  It  may  need  to  be 
touched  up  with  a  solution  of  nitrate  of  silver,  but  will 
ordinarily  heal  promptly  if  kept  clean. 


KRAUROSIS 

Kraurosis  is  a  process  of  sclerosis  involving  the  struc- 
tures of  the  vulva.  The  labia  minora  disappear.  The 
orifice  of  the  vagina  becomes  greatly  contracted.  The  tis- 
sues lose  their  elasticity  and  tear  readily,  especially  during 
labor.  The  course  of  the  disease  is  slow,  the  prognosis  is 
unfavorable,  and  the  results  of  treatment  have  been  un- 
satisfactory. 

VARICOCELE 

Varicocele  of  the  vulva  is  an  enlargement  of  the  veins  of 
the  vulva  due  to  pressure  within  the  pelvis.  It  is  most 
commonly  seen  in  association  with  pregnancy.  It  may  be 
due  to  any  intrapelvic  growth  which  exerts  pressure  upon 
the  veins.  There  is  some  tumefaction  of  the  vulva,  and  the 
veins  can  usually  be  seen  through  the  thin  epidermis. 
Evenly  distributed,  constant  pressure  for  a  short  time 
empties  the  veins  and  causes  a  disappearance  of  the  tunic- 
faction.     Hemorrhage  may  occur  from  a  rupture  of  our 


28  DISEASES    OF    THE    VULVA 

of  the  veins.    This  hemorrhage  can  be  controlled  by  direct 
pressure  or  by  ligation. 

Treatment.  —  Ordinarily  no  treatment  is  necessary,  be- 
cause the  condition  disappears  when  the  cause  of  it  is 
removed. 

HEMATOMA 

A  hematoma  of  the  vulva  is  a  collection  of  blood  in  the 
loose  connective  tissue. 

Etiology.  —  The  rupture  of  the  vessels  from  which  the 
blood  escapes  is  due  in  most  instances  to  an  injury  received 
during  labor,  but  may  result  from  falls  or  blows. 

Pathology.  —  When  the  blood  is  first  poured  out  it  dis- 
sects the  tissues  in  the  direction  of  least  resistance.  The 
blood  remains  fluid  for  some  time,  forming  a  rounded,  fluc- 
tuating mass.  If  not  relieved,  the  blood  clots  and  forms 
a  semi-solid  mass.  If  not  disturbed,  many  of  the  smaller 
collections  will  be  completely  absorbed.  But  the  process 
of  absorption  is  slow,  and  before  it  is  completed  many  of 
the  larger  collections  become  infected  and  abscesses  are 
formed. 

Symptoms  and  Diagnosis.  —  A  tumor  makes  its  appear- 
ance a  few  hours  after  the  time  the  injury  has  been  re- 
ceived. The  tumor  is  of  a  dark  purple  color.  It  is  at 
first  soft  and  fluctuating;  but  after  the  blood  clots  it 
becomes  somewhat  firmer.  It  usually  causes  very  little 
pain.  There  is  no  local  rise  of  temperature  unless  infection 
occurs. 

Treatment.  —  When  a  hematoma  is  small,  it  may  be  let 
alone  and  will,  as  a  rule,  disappear  by  absorption.  When 
it  is  large,  a  small  incision  should  be  made  into  it,  the  blood 
clot  pressed  out,  and  a  compress  put  on  in  such  a  position 
as  to  collapse  the  cavity.  If  it  becomes  infected,  it  should 
be  opened  freely  and  drained. 


EPITHELIOMA 


29 


EPITHELIOMA 


Epithelioma  of  the  vulva,  like  all  cancerous  growths,  is  a 
disease  most  frequently  met  with  in  individuals  past  middle 
life. 

Pathology.  —  The  growth  begins  at  the  junction  of  the 
skin  and  mucous  membrane.  It  makes  its  appearance  as 
a  small  nodule.  As  the  growth  ex- 
tends it  obstructs  the  blood-vessels 
and  cuts  off  the  blood  supply  to  its 
central  portion.  The  latter  breaks 
down,  leaving  a  crater-like  ulcer, 
with  everted  indurated  edges  from 
which  comes  an  ichorous  discharge. 
It  spreads  by  direct  continuity  of 
tissue  and  through  the  lymphatics. 
The  inguinal  glands  become  in- 
volved comparatively  early.  A 
microscopical  examination  shows 
columns  of  epithelial  cells  growing- 
downward  and  displacing  the  other 
tissues  of  the  vulva   (Fig.  5). 

Diagnosis.  —  The  age  of  the  pa- 
tient, the  duration  of  the  process, 
and  the  elevated  indurated  edges  are  usually  suffi- 
cient for  a  diagnosis.  To  confirm  this  diagnosis  a  small 
section  may  be  taken  out  for  microscopical  examination. 

Treatment.  —  The  treatment  consists  in  the  excision  of 
the  growth.  This  is  usually  best  done  by  beginning  below 
and  dissecting  upwards.  To  prevent  excessive  hemorrhage, 
as  soon  as  the  lower  part  of  the  tumor  is  freed,  the  wound 
should  be  closed  from  below  upward  by  deep  sutures  that 
go  entirely  beneath  the  dissected  surface.     This  alternate 


Fig.  4.— 
the  Vulva. 


Epithelioma  of 


30 


DISEASES    OF    THE    VULVA 


dissection  and  suturing  is  carried  upward  until  the  whole 
growth  is  removed.  It  may  be  necessary  to  remove  nearly 
the  whole  of  the  vulva ;  but  the  normal  tissues  of  this  part 
of  the  body  are  so  elastic  that  there  is  no  difficulty  in  closing 
very  extensive  wounds. 


Fig.  5.  —  Epithelioma  of  the  Vulva.  (Photomicrograph.)  The  epithelial 
cells  are  seen  growing  downward  and  displacing  the  connective  tissue.  Several 
epithelial  pearls  are  in  the  field. 


ELEPHANTIASIS 

In  elephantiasis  the  labia  are  enormously  enlarged,  but 
at  the  same  time  they  preserve,  to  a  certain  extent,  their 
original  outlines.  The  mass  is  made  up  of  an  overgrowth 
of  connective  tissue.  The  growth  is  a  very  slow  one.  Some- 
times the  more  dependent  portions  become  gangrenous. 
The  majority  of  the  cases  that  are  seen  here  are  thought 
to  be  of  syphilitic  origin.    In  hot  climates  elephantiasis  is 


INGUINAL    HEKNIA 


31 


seen  comparatively  frequently  and  is  said  to  be  due  to  the 
filaria  sanguinis  liominis. 
Treatment.  —  The  treatment  is  excision  of  the  growth. 


Fig.  6.  —  Elephantiasis  of  the  Vulva. 

INGUINAL   HERNIA 

An  inguinal  hernia  in  the  female  comes  down  through 
the  inguinal  canal  into  the  labium  major.  It  forms  a 
rounded  soft  tumor  that  disappears  when  the  patient  is  in 
the  recumbent  position.  It  gives  an  impulse  on  coughing. 
When  it  contains  intestine  it  is  tympanitic  on  percussion, 
and  when  it  contains  only  the  omentum  it  is  dull  on 
percussion. 

Treatment.  —  The  treatment  is  the  same  as  that  for  in- 
guinal hernia  in  the  male. 


HYDROCELE 

Hydrocele  is  a  distention  with  fluid  of  a  patulous  portion 
of  the  canal  of  Nuck.     It  presents  the  appearance  of  a 


32 


DISEASES    OE    THE    VULVA 


rounded  tumor  in  the  upper  part  of  the  labium  major,  and 
is  usually  so  tense  that  very  little  fluctuation  can  be  de- 
tected. It  does  not  disappear  either  on  pressure  or  change 
of  position.     It  is  translucent,  and  all  indications  of  an 


* 


Fig.  7.  —  Elephantiasis.  (Photomicrograph.)  On  the  surface  is  seen  a  thin 
layer  of  squamous  epithelium.  Beneath  this  the  whole  tumor  is  made  up  of  loose 
connective  tissue. 

inflammatory  process  are  absent.  It  is  dull  on  percussion, 
and  a  thin  watery  fluid  can  be  drawn  off  with  a  hypodermic 
syringe.    It  increases  in  size  very  slowly. 

Treatment.  —  The  sac  should  be  dissected  out  and  the 
wound  closed  by  sutures. 


FIBROIDS 

Fibroids  occur  rarely  in  any  part  of  the  vulva.     They 
are  round,  hard  tumors.    They  increase  in  size  very  slowly. 


VENEREAL    WARTS 


33 


They  are  not  painful,  and  give  trouble  only  on  account  of 
their  size  and  position.  They  have  a  tendency  to  become 
pedunculated. 

Treatment.  —  When  the  fibroid  is  pedunculated  the  ped- 
icle may  be  cut  through  and  ligated.  When  they  are  sessile 
they  can  be  cut  down  upon  and  hulled  out.  The  cavity  is 
closed  by  catgut  sutures. 


VENEREAL   WARTS 

Venereal  warts  are  of  two  varieties,  —  the  pedunculated 
venereal  warts  which  are  due  to  gonorrheal  or  other  irri- 
tating vaginal  discharges,  and  the  flat 
chondylomata  which  are  of  syphilitic 
origin.  The  gonorrheal  warts  may  be 
few  and  small,  or  they  may  spread  over 
the  entire  vulva  and  perineum.  On 
microscopical  examination  they  are 
shown  to  have  a  connective  tissue  stem 
covered  thickly  with  many  layers  of 
heavy  squamous  epithelium  (Fig.  9). 
They  do  not  penetrate  into  the  tissues 
of  the  vulva  beneath  the  point  of  ori- 
gin. The  growth  is  always  above  the 
original  level  from  which  it  started. 
The  warts  are  soft  and  spring  up 
rapidly.  They  give  off  an  acrid  serous 
discharge  and  bleed  readily.  The 
syphilitic  chondylomata  are  flat  or 
have  their  borders  slightly  elevated. 
They  are  of  a  grayish  white  color. 

Treatment.  —  In  the  treatment  of  the  pedunculated  warts 
the  point  of  first  consideration  is  to  treat  the  source  of  the 
irritating  discharge  causing  them.     In  many  cases  it  is 


Fig.  8.  —  Venereal 
Warts. 


34 


DISEASES    OP    THE    VULVA 


necessary  to  remove  the  warts  either  with  a  knife  or  cau- 
tery. When  the  warts  are  removed  with  a  knife,  the  in- 
cisions are  very  superficial  and  can  be  closed  entirely  by 
sutures.  If  the  cautery  is  used,  it  is  best  to  dust  the  parts 
afterward  thoroughly  with  a  powder  of  equal  parts  of  bis- 
muth and  calomel.     The  syphilitic  chondylomata,  beyond 


Fig.  9.  —  Venereal  Warts.  (Photomicrograph.)  The  warts  are  shown 
to  be  made  up  of  connective  tissue  stems  covered  with  many  layers  of  stratified 
squamous  epithelium. 

keeping  them  cleansed,  require  no  local  treatment.  They 
usually  heal  rapidly  under  constitutional  treatment  for 
syphilis. 


INJURIES    TO    THE   VULVA 

Besides  the  injuries  received  during  labor,  wounds  of 
the  vulva  may  occur  from  blows  or  more  frequently  from 
falls.  Any  cuts  that  are  received,  especially  about  the 
bulbs  of  the  vestibule,  bleed  very  profusely.     The  hemor- 


INFECTION    OF    BAKTHOLIN'S    GLANDS  35 

rhage  can  be  controlled  temporarily  by  direct  pressure  and 
permanently  by  sutures  that  go  entirely  under  the  injured 
part.  It  is  not  practical  to  attempt  to  tie  the  bleeding 
vessels  separately. 

INFECTION    OF    BARTHOLIN'S    GLANDS 

The  vulvo-vaginal,  or  Bartholin's,  glands  frequently  be- 
come infected,  and  as  a  result  of  infection  we  have  three 
conditions  to  be  considered,  —  an  infection  of  the  gland 
with  a  patulous  duct,  abscess  of  the  gland,  and  retention 
cyst. 

Infection   of   the   Vulvo- Vaginal,   Glands   with 
Patulous  Duct 

The  glands  are  frequently  infected  by  gonococci,  and  the 
infection  lingers  in  them  long  after  the  mucous  membranes 
of  the  vulva  and  the  vagina  recover.  When  infected,  the 
gland  is  slightly  enlarged  and  tender  and  the  orifice  of  the 
duct  is  red.  By  pressure  between  the  thumb  and  fingers 
a  small  amount  of  pus  can  be  expressed. 

Treatment.  —  Gentle  massage  of  the  gland  to  express  the 
purulent  contents  and  frequent  antiseptic  douches  usually 
lead  to  recovery. 

Abscess  of  the  Vulvo-Vaginal  Gland 

An  abscess  of  the  vulvo-vaginal  gland  produces  an  ovoid 
tumor  just  opposite  the  orifice  of  the  vagina  on  one  side, 
at  about  the  junction  of  the  middle  and  lower  third  of  the 
vulva.  There  is  a  history  of  previous  infection.  The  tumor 
forms  rapidly.  The  duct  of  the  gland  is  usually,  though 
not  always,  closed.  There  is  pain,  redness,  and  a  local  rise 
of   temperature   that   indicates   an   inflammatory   process. 


36 


DISEASES    OF    THE    VULVA 


The  tumor  fluctuates.  The  fluctuation  can  be  made  out 
most  plainly  if  the  labium  is  everted  and  the  mass  palpated 
through  the  mucous  membrane. 

Treatment.  —  In  the  acute  cases,  when  the  abscess  is 
large,  it  should  be  opened  through  the  side  covered  with 
mucous  membrane  and  drained.  In  chronic  cases  the  entire 
remains  of  the  gland  must  be  dissected  out. 

Eetention   Cyst   of  the 
Vulvo- Vaginal   Gland 

A  retention  cyst  is  an 
accumulation  within  the 
gland  of  the  normal  se- 
cretion of  the  gland 
after  the  duct  has  be- 
come occluded  as  the  re- 
sult of  a  mild  infection. 
It  is  a  small  round 
tumor  that  increases  in 
size  very  slowly  and  has 
none  of  the  symptoms 
of  an  inflammatory  pro- 
cess.   Its  location  helps  to  determine  its  character. 

Treatment.  —  Dissect  out  the  entire  gland.  If  any  por- 
tion of  the  cyst  wall  is  allowed  to  remain  the  cyst  will  refill. 
This  is  apparently  a  very  slight  operation,  but  it  should 
be  done  under  a  general  anesthetic,  because  it  requires  a 
deeper  dissection  than  appearances  would  indicate. 


Fig.    10.  —  Abscess 
Gland. 


of    Bartholin's 


IMPERFORATE    HYMEN 

An  imperforate  hymen  completely  closes  the  orifice  of  the 
vagina.     This  is  a  congenital  condition  and  is  usually  not 


IMPERFORATE    HYMEN  37 

discovered  until  after  puberty.  After  the  age  of  puberty 
the  patient  complains  of  having  recurring  pains  in  the  pelvis 
at  what  would  be  the  menstrual  period,  but  no  blood  is 
passed.  The  menstrual  blood  gradually  accumulates  in  the 
vagina.  Afterwards  it  distends  the  uterus,  and  sometimes 
even  the  tubes  are  found  distended.  The  patients  usually 
state  that  they  have  never  menstruated,  that  they  have  had 
recurring  pains  in  the  pelvis,  and  that  they  have  a  tumor 
in  the  lower  part  of  the  abdomen  that  is  slowly  increasing 
in  size. 

Diagnosis.  —  By  inspection  a  thin  discolored  hymen  is 
seen  bulging  between  the  labia.  By  digital  examination 
through  the  rectum  a  large  fluctuating  mass  is  felt  in  the 
pelvis. 

Treatment.  —  An  incision  is  made  into  the  hymen  and  the 
blood  drained  out.  If  the  uterus  is  distended,  it  is  best 
to  pack  it  lightly  with  plain  sterile  gauze.  To  improve 
the  drainage  put  the  patient  in  the  erect  position.  These 
cases  are  easily  infected,  because  the  retained  blood  is  an 
excellent  culture  medium  for  bacteria. 


CHAPTER    IV 

DISEASES    OF    THE    VAGINA 

ANATOMY 

The  vagina  is  that  part  of  the  genital  tract  extending 
from  the  vulva  to  the  cervix.  The  walls  of  the  vagina  are 
made  up  of  mucous  membrane,  connective  tissue,  and  mus- 
cular tissue.  The  mucous  membrane  is  thrown  into  folds 
that  are  much  more  prominent  in  the  nullipara  than  they 
are  in  women  who  have  borne  children.  The  surface  of  the 
mucous  membrane  is  covered  with  stratified  squamous  epi- 
thelium (Fig.  11).  There  are  no  glands  in  the  mucous 
membrane.  Immediately  beneath  the  epithelial  layer  is  a 
thin  layer  of  firm  connective  tissue,  and  beneath  this  is 
a  layer  of  loose  connective  tissue.  The  main  thickness 
of  the  wall  of  the  vagina  is  made  up  of  muscular  fibers 
which  are  directly  continuous  with  those  of  the  uterus. 
These  muscular  fibers  are  arranged  more  or  less  circularly 
and  longitudinally.  There  is  no  vaginal  sphincter.  The 
levator  ani  is  the  muscle  that  serves  to  close  the  orifice  of 
the  vagina.  The  peritoneum  covers  a  portion  of  the  upper 
part  of  the  posterior  wall.  The  vagina  is  not  a  tubular 
canal  but,  when  distended,  is  distinctly  balloon-shaped. 
The  cervix  is  inserted  into  the  anterior  vaginal  wall  where 
the  diameter  of  the  vagina  is  greatest.  This  makes  the 
posterior  wall  apparently  very  much  longer  than  the  an- 
terior wall.  When  at  rest  the  anterior  and  posterior  walls 
lie  in  contact  with  each  other.    The  surfaces  are  kept  moist 

38 


VAGINITIS 


39 


by  the  secretion  of  the  epithelium  covering  them.  In  this 
normal  secretion  is  found  a  large  number  of  non-pathogenic 
micro-organisms.  The  most  important  of  these  is  the  acid 
secreting  germ  of  Doederlein. 


■ 


Fig.  11.  —  Normal  Vaginal  Epithelium.     (Photomicrograph.) 


VAGINITIS 

Vaginitis  is  an  inflammation  of  the  vagina  due  to  some 
infecting  micro-organism.  All  forms  of  vaginitis  are  rela- 
tively rare.  This  is  due  in  part  to  the  heavy  squamous 
epithelial  lining  of  the  vagina,  which  is  a  very  great  pro- 
tection against  infection,  and  in  part  to  the  protection 
afforded  by  the  presence  of  the  numerous  non-pathogenic 
micro-organisms  which  exert  a  deleterious  influence  upon 
pathogenic  bacteria. 


40  DISEASES    OF    THE    VAGINA 

GONORRHEAL    VAGINITIS 

Gonorrheal  vaginitis  is  seen  in  association  with  gonor- 
rheal infection  of  other  parts  of  the  genital  tract.  It  is 
usually  associated  with  vulvitis,  urethritis,  and  infection  of 
the  cervical  canal.  The  mucous  membrane  is  swollen,  red, 
and  tender,  and  gives  off  a  profuse  purulent  discharge. 
In  the  earlier  stages  of  infection  gonococci  can  be  readily 
demonstrated  in  the  discharge.  In  the  later  stages  of  in- 
fection the  gonococci  are  very  difficult  to  find. 

Treatment.  —  In  the  acute  stages  the  patient  should  be 
kept  in  bed  and  the  vagina  douched  with  hot  normal  salt 
solution  or  mild  antiseptic  solutions.  As  soon  as  the  first 
very  acute  stage  is  over,  the  vagina  should  be  distended  by 
a  speculum  and  the  entire  vaginal  wall  painted  with  a 
solution  of  nitrate  of  silver,  twenty  or  thirty  grains  to  the 
ounce.  If  necessary  the  application  of  nitrate  of  silver  can 
be  repeated  every  forty-eight  hours.  After  the  first  appli- 
cation of  nitrate  of  silver  the  vagina  should  be  douched 
three  times  a  day  alternately,  with  one  to  five  thousand 
bichloride  of  mercury  solution,  and  a  weak  solution  of  one 
of  the  astringents,  such  as  sulphate  of  zinc,  alum,  or  tannic 
acid. 

Follicular  Vaginitis 

Follicular  vaginitis  is  found  most  frequently  during 
pregnancy,  or  just  after  the  menstrual  period.  Some 
patients  have  a  tendency  to  have  recurring  attacks  with 
each  menstrual  period.  The  part  of  the  vaginal  wall 
affected  is  that  just  surrounding  the  cervix.  It  presents 
the  appearance  of  numerous  small  red  areas  with  white 
centers.  It  produces  a  profuse  whitish  vaginal  discharge. 
The  discharge  with  the  burning  and  the  irritation  due  to  it 
are  the  only  symptoms. 


OTHER    INFECTIONS    OF    THE    VAGINA  41 

Treatment.  —  Paint  the  infected  area  with  a  sol  ution  of 
nitrate  of  silver,  thirty  grains  to  the  ounce.  After  that 
use  a  vaginal  douche  of  normal  salt  solution  twice  daily. 

Diphtheritic  Vaginitis 

Diphtheria  of  the  vagina  can  be  recognized  by  the  pres- 
ence of  the  Klebs-Loeffler  bacillus.  It  should  not  be  mis- 
taken for  the  pseudo-diphtheritic  membrane  frequently  seen 
in  streptococcus  infections  after  labor. 

Aphthous  Vaginitis 

This  is  a  rare  condition,  due  to  a  growth  of  odium  albi- 
cans or  other  fungi.  Large  whitish  deposits  are  found  on 
the  surface  of  the  vagina. 

Treatment.  —  Cleanse  the  infected  surface  thoroughly, 
apply  a  one  to  two  thousand  bichloride  of  mercury  solution 
and  place  in  the  vagina  a  glycerin  tampon.  The  treatment 
should  be  repeated  daily. 

OTHER   INFECTIONS    OF   THE    VAGINA 

Streptococci  and  other  pus-producing  organisms  occa- 
sionally infect  the  mucous  membrane  of  the  vagina.  The 
symptoms  are  similar  to  those  produced  by  gonorrheal 
infection.  The  local  treatment  is  the  same  as  for  gonor- 
rheal infection. 

The  gas  bacillus  infects  the  vaginal  mucous  membrane 
during  pregnancy  more  frequently  than  at  any  other  time. 
It  produces  small  vesicles  from  which  the  fluid  that  first 
fills  them  may  disappear  to  be  replaced  by  gas. 

Treatment.  —  Puncture  the  vesicles  and  use  as  a  vaginal 
douche  a  solution  of  boracic  acid. 


42  DISEASES    OF    THE    VAGINA 

Tuberculosis  of  the  Vagina 

Tuberculosis  of  the  vagina  is  almost  invariably  asso- 
ciated with  tuberculosis  in  other  parts  of  the  body.  The 
sources  of  the  local  infection  are  discharges  from  the  uterus 
or  from  recto-vaginal  or  vesico-vaginal  fistulae,  or  the  infec- 
tion may  be  introduced  directly  from  without.  It  produces 
an  ulcer  of  grayish  color,  with  sharply  defined  borders  of 
reddened,  thickened  mucous  membrane.  It  can  be  distin- 
guished from  other  ulcers  of  the  vaginal  wall  by  the  finding 
of  the  tubercle  bacillus. 

Treatment.  —  As  the  lesion  in  the  vagina  is  practically 
always  secondary,  the  treatment  is  palliative. 

Paravaginitis 

Paravaginitis  is  a  streptococcus  infection  of  the  loose 
connective  tissue  of  the  vagina.  There  is  much  swelling 
of  the  vaginal  wall,  and  there  is  a  general  rise  of  bodily 
temperature  with  local  pain  and  tenderness.  The  process 
tends  to  suppuration  and  sloughing. 

Treatment.  —  An  incision  should  be  made  early  into  the 
infected  area  and  drainage  promoted  by  packing  the  in- 
cision lightly  with  gauze. 

Adhesive  Vaginitis 
(Senile  Vaginitis) 

Adhesive  or  senile  vaginitis  in  many  instances  is  not  a 
true  inflammatory  process,  but  is  a  result  of  malnutrition. 
The  epithelium  desquamates  and  the  exposed  surfaces  of 
the  opposing  vaginal  walls  adhere.  When  an  infection  is 
added  to  this  condition,  the  vaginal  walls  are  reddened  and 


STENOSIS    OF    THE    VAGINA  43 

there  is  an  irritating  muco-purulent  discharge.  The  dis- 
charge causes  a  burning  sensation  about  the  vulva  and  an 
obstinate  pruritus. 

Treatment.  —  The  disease  being  a  local  manifestation  of 
the  general  debility  of  the  patient,  it  is  obvious  that  local 
treatment  is  of  little  value.  Vaginal  douches  of  normal  salt 
solution  or  of  solutions  of  the  milder  astringents  relieve  to 
some  extent  the  symptoms. 

Vaginitis  in  Children 

Vaginitis  in  children  is  nearly  always  due  to  a  gonorrheal 
infection.  The  infection  is  usually  an  indirect  one,  and  is 
acquired  from  infected  sheets,  towels,  or  bath-tubs.  In 
exceptional  cases  it  is  a  direct  infection.  The  vagina  and 
the  vulva  are  red  and  somewhat  swollen.  There  is  a  pro- 
fuse purulent  discharge  in  which  the  gonococci  are  readily 
found.  The  urethra  is  sometimes  involved,  but  there  is 
much  less  tendency  for  the  infection  to  extend  to  the  uterus 
and  tubes  than  there  is  in  the  adult. 

Treatment.  —  With  a  soft  rubber  ear-syringe  irrigate  the 
vagina  with  normal  salt  solution.  Immediately  afterwards 
irrigate  with  a  solution  of  two  grains  of  nitrate  of  silver 
to  the  ounce.  Irrigation  with  the  nitrate  of  silver  solution 
should  be  repeated  every  second  day.  On  the  alternate  days 
the  vagina  should  be  douched  with  a  bichloride  solution,  one 
to  four  thousand,  or  a  solution  of  sulphate  of  zinc,  one 
grain  to  the  ounce.  The  disease  is  very  persistent,  and  the 
treatment  should  be  kept  up  until  the  discharge  has  entirely 
ceased. 

STENOSIS    OF   THE   VAGINA 

Stenosis  of  the  vagina  is  a  narrowing  of  the  vaginal 
calibre  due  to  a  failure  of  development  or  to  cicatricial  con- 


44  DISEASES    OF    THE    VAGINA 

tractions  following  injuries  to  the  vagina.  These  injuries 
to  the  vagina  may  be  received  during  labor,  or  they  may 
result  from  ulcerations  due  to  foreign  bodies  in  the  vagina, 
such  as  pessaries,  or  from  sloughing  of  the  vaginal  wall 
after  a  streptococcus  infection  of  the  cellular  tissues  of  the 
vagina.  The  condition  is  usually  discovered  when  making 
a  vaginal  examination  for  pelvic  pain.  There  are  no  char- 
acteristic symptoms. 

Treatment.  —  The  cicatricial  bands  may  be  divided  and 
the  vagina  packed  with  a  glass  or  hard-rubber  plug  made 
for  the  purpose,  but  it  is  manifestly  impossible  to  remove 
the  cicatricial  tissue  in  acquired  stenosis.  While  the  calibre 
of  the  vagina  may  be  increased  by  this  treatment,  its  elas- 
ticity cannot  be  restored. 

ATRESIA   OF   THE   VAGINA 

Atresia  of  the  vagina  is  a  complete  closure  of  the  vaginal 
canal.  It  may  be  either  congenital  or  acquired.  An  ac- 
quired atresia  may  be  due  to  an  inflammatory  process  which 
destroys  the  epithelium  allowing  the  two  vaginal  walls  to 
become  adherent,  or  it  may  result  from  a  severe  injury 
to  the  vagina.  The  symptoms  and  pathological  conditions 
produced  by  the  accumulation  of  menstrual  blood  above  the 
point  of  obstruction  are  the  same  as  those  given  for  im- 
perforate hymen.  The  extent  of  the  atresia  can  be  dis- 
covered by  digital  examination  through  the  rectum. 

Treatment.  —  With  a  sound  in  the  bladder  for  a  guide 
anteriorly  and  one  finger  in  the  rectum  as  a  guide  pos- 
teriorly, a  transverse  incision  is  made  in  the  presenting 
vaginal  wall  and  the  opening  is  carried  upward  by  blunt 
dissection.  Great  care  should  be  taken  not  to  injure  either 
the  bladder  or  the  rectum.  After  the  accumulated  blood  is 
drained  out  the  entire  cavity  is  loosely  packed  with  gauze, 


VAGINAL    CYSTS 


L5 


It  will  be  necessary  to  use  either  a  gauze  pack  or  a  glass 
or  hard-rubber  vaginal  plug  for  a  considerable  length  of 
time  to  prevent  the  vaginal  walls  from  again  adhering. 

VAGINAL    CYSTS 

Vaginal  cysts  are  of  two  varieties,  occlusion  cysts  and 
cysts  developing  in  a  patulous  portion  of  Gartner's  duct. 
Occlusion  cysts  are  usually  found  in  the  posterior  vaginal 


Fig.  12.  —  Vaginal  Cysts. 


wall  and  are  secondary  to  injuries  to  the  vaginal  wall  re- 
ceived during  labor.  In  the  process  of  healing  of  a  vaginal 
tear,  if  a  small  fragment  of  epithelium  be  overgrown,  it 
continues  to  develop  and  eventually  lines  a  small  cavity. 
The  secretion  from  this  epithelium  gradually  distends  the 
cavity  and  forms  a  cyst.  The  cysts  are  usually  small  in 
size  and  give  rise  to  very  little  disturbance.  The  cysts 
developing  in  Gartner's  duct  are  found  just  a  little  to  one 


46  DISEASES    OF    THE    VAGINA 

side  or  other  of  the  median  line  in  the  anterior  vaginal 
wall.  They  may  be  single  or  there  may  be  a  series  of  them 
corresponding  to  several  dilatations  in  the  duct.  They  are 
thin-walled  cysts  filled  with  an  almost  clear  fluid.  In  ex- 
ceptional instances  they  communicate  with  a  broad-liga- 
ment cyst.  They  develop  slowly  but  may  become  sufficiently 
large  to  fill  up  the  entire  calibre  of  the  vagina.  They 
fluctuate,  and  are  smooth,  round,  and  translucent. 

Treatment.  —  Make  an  incision  through  the  mucous  mem- 
brane over  the  cyst.  Dissect  out  the  entire  cyst.  If  it  is 
in  the  anterior  vaginal  wall  care  should  be  taken  not  to 
injure  the  urethra.  Close  up  the  cavity  with  fine  catgut 
sutures. 

SOLID    TUMORS    OF    THE    VAGINA 

Fibroids,  primary  carcinoma,  sarcoma,  and  chorio- 
epithelioma  of  the  vagina  are  occasionally  met  with. 

Fibroids  may  occur  as  sessile  or  pedunculated  tumors. 
They  are  easily  recognized  by  being  round  and  hard. 
Sessile  fibroids  may  be  removed  by  making  an  incision 
through  the  mucous  membrane  over  the  tumor  and  enu- 
cleating it.  The  pedunculated  tumor  may  be  removed  by 
tying  off  the  pedicle  and  cutting  through  it. 

Primary  carcinoma  of  the  vagina  usually  occurs  in  a  pro- 
lapsed anterior  wall.  In  the  earlier  stages  the  vaginal  wall 
is  thickened,  but  it  is  usually  necessary  to  examine  a  section 
of  it  with  the  microscope  to  be  sure  of  the  diagnosis. 

Sarcoma  usually  forms  a  round  soft  mass.  It  may  start 
from  any  portion  of  the  vaginal  wall. 

Chorio-epithelioma  may  occur  in  the  vagina  either  with 
or  independent  of  a  similar  growth  in  the  uterus.  It  forms 
a  round  dark  red,  soft  mass.  Microscopical  examination 
shows  that  it  is  made  up  of  large  unlined  blood  spaces,  large 
decidua-like  cells,  and  a  few  syncytial  cells. 


DYSPARUNIA  47 

VAGINISMUS 

Vaginismus  is  a  painful  spasmodic  contraction  of  the 
vagina  set  up  by  attempts  at  coition.  It  is  usually  a  neu- 
rotic condition,  but  may  be  due  to  urethral  caruncle,  irri- 
table hymen,  inflamed  carunculae  myrtiformes,  or  fissure 
of  the  vulva.  The  spasm  is  usually  produced  when  an 
attempt  is  made  to  introduce  anything  into  the  vagina,  but 
cases  are  seen  where  the  contractions  are  very  severe  on 
attempts  at  coition  and  entirely  absent  on  digital  examina- 
tion or  when  a  speculum  is  introduced. 

Treatment.  —  When  a  local  cause  can  be  discovered  it 
should  be  removed.  In  some  of  the  milder  cases  an  appli- 
cation to  the  vulva  of  an  ointment  containing  cocaine  just 
before  retiring  is  all  that  is  necessary.  Gradual  dilatation 
of  the  orifice  of  the  vagina  with  bougies  under  cocaine, 
forcible  dilatation  under  general  anesthesia,  and  incision 
into  the  vaginal  sulci  have  all  been  used  successfully. 

DYSPARUNIA 

Dysparunia  or  painful  coition  is  frequently  confused  with 
vaginismus.  Vaginismus  prevents  coition;  dysparunia  is 
pain  during  the  act  and  may  be  due  to  a  large  number  of 
pathological  conditions.  Some  of  the  more  common  causes 
are  intact  hymen,  vulvitis,  urethral  caruncle,  irritable 
carunculae  myrtiformes,  vaginitis,  cervicitis,  prolapsed 
ovaries,  salpingitis,  etc. 


CHAPTER   V 

INJURIES    TO    THE    PELVIC    FLOOR 

ANATOMY 

The  pelvic  floor  or  diaphragm  is  made  up  of  the  levator 
ani  muscle  and  the  fascia  which  encloses  it.  The  levator 
ani  arises  on  either  side  anteriorly  from  the  pubis,  pos- 
teriorly from  the  inner  side  of  the  ischial  spine.  Between 
these  two  points  it  is  attached  to  the  whole  length  of  the 
arcus  tendineus.  In  the  median  line  posterior  to  the  rec- 
tum is  a  tendinous  raphe  into  which  the  muscle  from  both 
sides  is  inserted  and  which  is  attached  to  the  tip  of  the 
coccyx.  A  part  of  the  muscle  fibers  from  both  sides  inter- 
lace with  the  longitudinal  layer  of  the  muscular  fibers  of 
the  rectal  wall,  and  a  part  with  the  longitudinal  fibers  of 
the  muscular  wall  of  the  vagina. 

The  fascia  of  the  levator  ani  muscle  is  a  subdivision  of 
the  obturator  fascia.  From  the  arcus  tendineus,  or  white 
line,  two  laminae  are  given  off,  —  one,  the  recto-vesical  to 
the  visceral  surface  of  the  muscle,  the  other,  the  ischio- 
rectal to  the  parietal  aspect. 

These  two  laminas  of  fascia  support  the  greater  part  of 
the  dead  weight  that  bears  upon  the  pelvic  floor,  and  it 
is  only  following  severe  defects  in  the  fascia  that  descent 
of  the  pelvic  viscera  occurs.  The  injuries  to  the  birth  canal, 
which  occur  during  labor  and  which  are  ordinarily  spoken 
of  as  lacerations  of  the  perineum,  have  little  influence  upon 
the  pelvic  viscera  unless  the  fascia  of  the  levator  ani  is 
damaged. 

48 


LACERATION    OF    THE    PERINEUM 


49 


LACERATION   OF    THE    PERINEUM 

Etiology.  —  The  most  frequent  cause  of  injury  to  the 
perineum  is  the  too  rapid  delivery  of  the  head  of  the  child 
during  labor.  Other  causes  are  an  unusually  large  size 
of  the  child,  an  unusually  narrow  outlet  of  the  vagina,  fria- 
bility of  the  perineum  such  as  is  found  as  a  result  of 
kraurosis,  occiput  posterior  position,  and  the  unskilful  use 
of  the  obstetric  forceps. 


Fig.   13.  —  Relaxed  Va- 
ginal Outlet. 


Fig.    14.   —   Complete 
Tear  of  the  Perineum. 


Classification.  —  Injuries  to  the  perineum  are  classified 
in  a  great  variety  of  ways.  They  are  spoken  of  as  com- 
plete when  the  tear  extends  all  the  way  into  the  rectum, 
or  as  incomplete  when  the  sphincter  ani  is  not  injured. 
They  are  spoken  of  as  open  tears  when  the  injury  involves 
the  mucous  membrane  and  the  deeper  tissues,  or  as  sub- 


50  INJURIES    TO    THE    PELVIC    FLOOR 

mucous  tears  when  the  deeper  structures  are  injured  with- 
out a  tear  of  the  mucous  membrane.  Tears  of  the  perineum 
are  sometimes  classified  in  four  degrees.  The  first  degree 
includes  the  tears  of  the  mucous  membrane  only.  The 
second  degree  includes  the  tears  down  to  the  sphincter  of 
the  anus.  In  the  third  degree  the  sphincter  is  torn,  and 
in  the  fourth  degree  all  structures  including  the  rectum 
are  torn. 

The  majority  of  lacerations  of  the  perineum  are  to  one 
side  or  the  other  of  the  median  line,  and  frequently  the 
laceration  is  on  both  sides.  The  deeper  lacerations  occur 
on  the  side  corresponding  to  the  position  of  the  occiput  of 
the  child's  head  during  delivery,  and  this  being  more  fre- 
quently on  the  left  side,  the  tears  of  the  left  vaginal  sulcus 
are  more  frequent  and  deeper  than  those  of  the  right  sulcus. 
The  tear  will  sometimes  extend  down  to  and  around  one 
side  of  the  sphincter  without  going  through  it.  The  lateral 
tears  of  the  perineum  are  the  ones  which  most  seriously 
injure  the  levator  ani  muscle  and  its  fascia.  The  tears  in 
the  median  line  are  less  frequent  than  the  lateral  tears,  and 
while  their  appearance  is  that  of  grave  injury,  as  a  rule, 
unless  very  deep,  the  levator  ani  muscle  and  its  fascia  are 
not  materially  injured. 

Prolapse  of  the  pelvic  organs  more  frequently  follows 
the  lateral  tears  than  the  tears  in  the  median  line. 

Associated  Lesions.  —  As  associated  pathological  lesions 
and  results  of  injuries  to  the  perineum  we  have  subinvo- 
lution, retrodisplacement,  and  prolapse  of  the  uterus;  re- 
laxation of  the  broad  and  round  ligaments;  cystocele  and 
rectocele. 

Symptoms.  —  The  symptoms  are  very  largely  due  to  the 
associated  lesions.  There  is  pain  in  the  back,  a  sense  of 
loss  of  support  and  pressure  in  the  pelvis.  When  a  cysto- 
cele is  present,  the  bladder  very  commonly  becomes  infected 


LACERATION    OF    THE    PERINEUM  51 

and  the  patient  suffers  from  frequent  and  painful  micturi- 
tion. When  the  sphincter  ani  is  injured,  there  is  inconti- 
nence of  the  feces. 

Diagnosis.  —  The  diagnosis  of  perineal  tears  can  be  made 
usually  by  inspection,  but  where  there  has  been  a  sub- 
mucous injury,  or  in  cases  where  the  mucous  membrane  of 
the  vaginal  wall  and  pelvic  fascia  have  been  injured  with- 
out any  very  great  injury  to  the  skin,  the  appearance  may 
be  deceptive.  In  these  cases  by  inserting  the  forefinger  of 
each  hand  into  the  vagina  and  making  traction  gently  down- 
wards and  outwards,  it  will  be  observed  that  the  vaginal 
outlet  is  very  much  relaxed  (Fig.  13). 

In  complete  tears  of  the  perineum  the  extent  of  the  in- 
jury is  evident  from  observation.  The  anus  and  the  vagina 
form  one  opening.  The  sphincter  ani  is  drawn  out  nearly 
to  a  straight  line  just  below  the  anal  opening.  The  re- 
tracted ends  of  the  sphincter  are  marked  by  a  dimple  on 
either  side  of  the  anal  opening.  There  is  a  history  of 
incontinence  of  the  feces.  The  extent  of  the  tear  up  into 
the  rectum  may  be  readily  determined  by  the  introduction 
of  one  finger  into  the  rectum  and  the  thumb  into  the  vagina. 

Prophylaxis.  —  An  important  point  in  the  consideration 
of  injuries  to  the  perineum  is  the  means  for  their  pre- 
vention. It  is  recognized  that  there  is  a  certain  percentage 
of  cases  in  which  tears  in  the  perineum  during  labor  are 
unavoidable,  but  there  is  a  very  large  portion  where,  if 
proper  precautions  are  taken,  no  injury  will  result. 

Where  the  perineum  has  the  proper  degree  of  elasticity, 
its  injury  is  always  due  to  too  great  rapidity  of  delivery. 
This  rapidity  of  delivery  may  be  retarded  in  normal  cases 
by  the  use  of  chloroform  given  in  the  last  part  of  the 
second  stage  to  almost  or  quite  complete  anesthesia.  If 
no  anesthetic  is  used  the  patient  can  be  instructed  to  breathe 
rapidly  during  the  height  of  each  pain.    When  the  patient 


52       INJURIES  TO  THE  PELVIC  FLOOR 

breathes  continuously  it  is  impossible  for  her  to  fix  the 
abdominal  muscles.  The  chloroform  partly  or  completely  re- 
laxes the  abdominal  muscles.  In  either  instance  the  action 
of  the  abdominal  muscles  is  eliminated  and  the  pelvic 
floor  has  to  withstand  only  the  pressure  due  to  the 
uterine  contractions.  The  advance  of  the  head  under  the 
pressure  of  the  uterine  contractions  alone  can  be  retarded 
by  the  hands  over  the  occiput  of  the  child  and  over  the 
perineum.  By  these  measures  the  delivery  of  the  head 
can  be  delayed  until  the  perineum  is  fully  distended  and 
the  head  can  be  delivered  with  the  least  danger  to  the 
perineum. 

When  the  obstetric  forceps  are  used  the  patient  should 
be  under  complete  anesthesia.  Traction  on  the  forceps 
should  be  made  intermittently,  and  too  much  force  should 
not  be  used.  Time  should  be  allowed  for  the  complete  dis- 
tention of  a  perineum  before  the  extraction  of  the  head  is 
attempted.  The  best  obstetrician  is  not  the  one  who  can 
deliver  a  child  with  forceps  most  quickly,  but  the  one  who 
can  deliver  a  living  child  with  the  least  injury  to  the  mother. 

Treatment.  —  Immediate  Eepair.  —  All  injuries  to  the 
perineum  and  vaginal  walls  occurring  during  labor  should 
be  repaired  immediately.  The  labia  should  be  separated 
widely  and  then,  beginning  at  the  highest  point  of  the  tear 
in  the  vaginal  wall,  it  should  be  brought  together  with 
stitches  from  side  to  side,  put  in  at  right  angles  to  the 
vaginal  wound.  Each  stitch  should  be  tied  as  put  in.  After 
the  tear  in  the  vaginal  wall  is  completely  closed,  two  or 
three  relatively  shallow  stitches  through  the  skin  will  bring 
the  external  portion  of  the  wound  together.  For  the 
stitches  in  the  vaginal  wall  catgut  is  the  most  satisfactory 
material.  For  the  skin  stitches  chromosized  catgut  can  be 
used  with  very  good  results,  but  any  material  may  be  used. 
Silkworm-gut  gives  the  patient  a  great  deal  of  discomfort 


LACERATION    OF    THE    PERINEUM  53 

and  should  be  avoided.  If  the  tear  has  extended  up  into 
the  rectum  the  rectal  wall  should  be  sutured  first,  taking 
care  not  to  allow  the  edge  of  the  mucous  membrane  to  be 
turned  up  into  the  wound.  The  ends  of  the  torn  sphincter 
should  be  sought  for  and  stitched  together  by  two  catgut 
sutures  and  these  reinforced  by  two  non-absorbable  sutures 
which  pass  through  the  skin  and  through  the  ends  of  the 


Fig.  15.  —  Flap-splitting  Operation  for  Laceration  of  the  Perineum. 
First  step.  The  line  along  the  muco-cutaneous  border  indicates  the  line  of 
incision. 

sphincter.  The  remainder  of  the  tear  can  be  repaired  as 
previously  described,  just  as  though  the  rectum  and  sphinc- 
ter had  not  been  injured. 

Late  Repair.  —  Very  many  different  forms  of  operation 
have  been  devised  for  late  repair  of  the  perineum  and  the 
pelvic  floor.  Only  three  of  these  operations  will  be  de- 
scribed, —  the  flap-splitting  operation,  Emmet 's  operation, 
and  Hegar's  operation.  For  any  of  these  operations  the 
patient  is  prepared  as  described  under  operative  technique 
and  is  put  in  the  lithotomy  position. 


54 


INJURIES    TO    THE    PELVIC    FLOOE 


The  Flap-splitting  Operation.  —  Two  points  on  either 
side  of  the  vaginal  outlet  at  about  the  level  of  the  vulvo- 
vaginal glands  are  fixed  by  bullet  forceps.  Tension  is  made 
on  these  two  points  by  the  bullet  forceps,  and  an  incision  is 
made  from  one  fixed  point  to  the  other  in  the  lower  segment 
of  the  vaginal  outlet  along  the  border  of  the  junction  of  the 
mucous  membrane  and  the  skin  (Fig.  15).     The  mucous 


Fig.  16.  —  Flap-splitting  Operation.  Second  step.  The  mucous  mem- 
brane of  the  posterior  vaginal  wall  has  been  elevated  and  the  fascia  on  both  sides 
has  been  seized  by  forceps  and  drawn  up  to  be  sutured. 

membrane  is  then  dissected  up  from  the  floor  of  the  vagina. 
It  is  usually  necessary  at  the  beginning  of  this  dissection 
to  clip  with  a  knife  or  scissors  the  cicatricial  bands  about 
the  outlet  of  the  vagina,  but  when  these  are  separated,  the 
mucous  membrane  can  be  lifted  from  its  attachment  by 
blunt  dissection  as  high  as  is  necessary.  The  dissection 
must  be  carried  sufficiently  far  laterally  to  uncover  the  torn 
portions  of  the  levator  ani  muscle.  The  levator  ani  muscle 
and  its  fascia  are  then  grasped  by  mouse-toothed  forceps, 


LACERATION    OF    THE    PERINEUM 


55 


brought  into  view  (Fig.  16),  and  stitched  together  with  cat- 
gut sutures  over  the  rectum.  This  first  line  of  sutures 
(Fig.  17),  bringing  together  the  fascia  of  the  levator  ani 
muscle,  is  the  essential  portion  of  the  repair.  Other  inter- 
rupted sutures  are  put  in  above  these  to  bring  the  raw 
surfaces  together.  A  small  portion  of  the  superfluous 
mucous  membrane  is  trimmed  away.    A  purse-string  suture, 


Fig.  17.  —  Flap-splitting  Operation.  Third  step.  Two  sutures  have  been 
placed  in  the  fascia  and  tied.  The  third  one  has  been  placed  but  not  tied.  The 
suture  which  brings  together  the  upper  angles  of  the  wound  and  draws  down  the 
vaginal  flap  is  also  placed  but  not  tied. 


which  is  introduced  at  the  point  that  is  held  by  one  bullet 
forceps,  picks  up  the  free  edge  of  the  mucous  membrane  at 
several  points,  and  is  brought  out  on  the  opposite  side  at  the 
point  held  by  the  second  bullet  forceps.  When  this  suture 
is  tied  the  whole  vaginal  surface  of  the  wound  is  covered 
with  unbroken  mucous  membrane,  the  points  held  by  the 
bullet  forceps  are  brought  together,  and  the  mucous  mem- 
brane of  the  vagina  brought  down  to  these  points.     This 


56 


INJURIES  TO  THE  PELVIC  FLOOR 


suture  is  then  continued  downwards,  using  a  buttonhole 
stitch,  and  brings  together  the  skin  and  tissues  of  the  peri- 
neum just  beneath  the  skin  that  have  not  previously  been 
brought  together  by  the  buried  sutures.  Interrupted  sut- 
ures may  be  substituted  for  the  buttonhole  suture.  For 
the  buried  sutures,  number  three  plain 
catgut  is  used.  For  the  purse-string 
and  the  suture  of  the  skin,  number  two 
chromosized  catgut  is  used.  The  main 
advantages  of  this  operation  are  that 
it  reconstructs  a  firm  pelvic  floor,  there 
is  no  loss  of  tissue,  it  is  easily  and 
quickly  performed,  and  it  is  applicable 
to  a  very  wide  range  of  injuries. 

Emmet's  Operation.  —  The  points  on 
the   sides   of  the  vaginal   orifice  near 
the  opening  of  the  duct  of  each  vulvo- 
vaginal gland  are  fixed  in  exactly  the 
=jvl  same  way  as  in  the  flap-splitting  opera- 

Fig.  18.  —  Flap-split-  tion,  and,  in  addition,  with  bullet  f or- 

ting  Operation.    Fourth   cepg  a  third  point  j_B  fixe(j  in  ^e  median 
step.    All  the  sutures  have  .  .  .  . 

been  tied.  line  °*  the  posterior  vaginal  wall.    IJiis 

point  in  the  median  line  should  be 
sufficiently  far  forward  on  the  vaginal  wall  so  that  it  can 
be  brought  easily  to  the  points  held  by  the  bullet  forceps 
at  the  outlet  of  the  vagina.  It  must  be  sufficiently  far  back 
in  the  vaginal  wall  so  that  when  it  is  brought  forward,  all 
undue  relaxation  of  the  posterior  wall  is  taken  up.  With 
a  sharp  knife  the  surface  to  be  denuded  is  next  outlined. 
The  first  line  runs  from  the  bullet  forceps  on  one  side  of 
the  vaginal  outlet  along  the  junction  of  the  mucous  mem- 
brane and  the  skin  to  the  bullet  forceps  on  the  opposite  side. 
Using  the  line  running  from  the  point  of  insertion  of  the 
middle  forceps  to  the  point  held  by  one  of  the  forceps  at 


LACERATION    OF    THE    PEIMXEUM 


57 


the  vaginal  outlet  as  a  base,  a  triangle,  with  its  apex  as 
high  in  the  vaginal  sulcus  as  the  vaginal  tear  extended,  is 
marked  out.  The  same  sort  of  triangle  is  then  outlined  on 
the  other  side.  These  lines  completely  define  the  area  to 
be  denuded  (Fig.  19).  These  outlines  should  always  be 
drawn  before  any  denudation  is  done.  The  mucous  mem- 
brane is  then  lifted  up  by  dissecting  forceps  and  is  cut 


Fig.  19.  —  Emmet's  Operation  for  Laceration  of  the  Perineum. 
step.    The  dark  lines  outline  the  area  to  be  denuded. 


First 


away  in  strips  with  scissors  until  the  entire  area  which 
is  outlined  has  been  denuded.  Care  must  be  taken  not  to 
leave  any  islands  of  mucous  membrane. 

In  closing  the  wound,  the  beginning  should  be  made  at 
the  upper  angle  of  one  of  the  triangular  denudations.  The 
sutures  are  passed  in  at  right  angles  to  the  border  of  the 
denuded  surface,  carried  downward  to  the  bottom,  and 
then  upward  on  the  other  side,  emerging  at  right  angles  to 
the  border  of  denudation  on  the  opposite  side.     Three  or 


58 


IXJUKIES    TO    THE    PELVIC    FLOOK 


four  sutures  are  usually  sufficient  to  close  up  the  denuda- 
tion of  each  sulcus.  When  these  are  placed  and  tied,  a 
suture  is  started  through  the  skin  at  the  point  held  by  one 
of  the  bullet  forceps.  From  here  it  is  carried  under  the 
tongue  of  mucous  membrane  that  is  held  by  the  bullet  for- 
ceps in  the  floor  of  the  vagina,  and  is  brought  out  through 
the  skin  where  the  bullet  forceps  of  the  opposite  side  is 


Fig.  20.  —  Emmet's  Operation.  Second  step.  One  triangular  denudation  is 
closed  and  the  sutures  tied.  The  sutures  in  the  other  angle  are  placed  but  not 
tied.    The  skin  sutures  are  also  in  position. 


attached  (Fig.  20).  When  this  suture  is  tied  it  brings  to- 
gether the  three  points  originally  held  by  the  three  bullet 
forceps.  A  small  gap  is  left  in  the  skin  below  this  suture 
which  is  brought  together  by  interrupted  sutures  (Fig.  21). 
For  the  suture  material  either  silk,  linen,  or  catgut  can  be 
used. 

Hegar's  Operation.  —  Two  points  at  the  vaginal  outlet 
near  the  orifices  of  the  vulvo-vaginal  glands  are  fixed  by 
bullet  forceps.    On  the  posterior  vaginal  wall  with  a  knife 


LACERATION    OF    THE    PERINEUM 


59 


there  is  outlined  a  triangular  area  whose  base  extends  along 
the  junction  of  the  skin  and  mucous  membrane  from  one  of 
these  fixed  points  to  the  other,  and  whose  apex  is  high  up 
in  the  median  line  of  the  posterior  vaginal  wall.  The 
mucous  membrane  within  these  outlines  is  then  dissected 
off  with  scissors. 

Closure  of  the  wound  should  begin 
at  the  apex  of  the  triangle  of  denuda- 
tion on  the  posterior  vaginal  wall.  The 
needle  should  be  introduced  at  right 
angles  to  the  edges  of  the  wound  and 
carried  downward  and  inward  to  the 
median  line.  From  this  point  it  is  car- 
ried upward  and  backward  to  the  point 
opposite  its  insertion  (Fig.  22).  Each 
succeeding  suture  is  introduced  in  the 
same  manner.  The  result  of  passing 
the  sutures  in  this  way  is  to  lift  the 
floor  of  the  pelvis  upward  and  back- 
ward behind  the  symphysis.  When  the 
last  suture  in  the  vaginal  wall  is 
tied,  it  is  found  that  nearly  the  whole 
of  the  denuded  surface  is  closed.  A 
few  stitches  through  the  skin  complete 
the  operation. 

Repair  of  Complete  Tears  of  the  Perineum.  —  In  the 
repair  of  complete  tears  of  the  perineum  the  injury  to  the 
rectum  must  be  repaired  and  the  torn  ends  of  the  sphincter 
ani  brought  together.  The  edges  of  the  torn  rectum  can  be 
denuded  either  by  splitting  the  recto-vaginal  septum  or  by 
paring  the  torn  edges.  The  splitting  method  is  preferable 
because  no  tissue  is  destroyed.  The  rectum  can  be  closed 
by  either  catgut  or  fine  silk  sutures.  When  silk  is  used, 
the  suture  should  be  introduced  from  the  rectal  side  so 


Fig.  21.  —  Emmet's 
Operation.  Third  step. 
All  the  sutures  are  tied. 


60 


INJURIES    TO    THE    PELVIC    FLOOR 


that  the  knots  are  tied  in  the  rectum.  When  catgut  is  used, 
the  sutures  should  be  put  in  from  the  upper  side.  They 
should  not  penetrate  the  entire  thickness  of  the  rectal  wall. 
Care  should  be  taken  not  to  allow  the  edges  of  the  mucous 
membrane  to  turn  upward  into  the  wound,  because  it  will 
prevent  union. 


Fig.  22.  —  Hegak's  Operation  for  Laceration  of  the  Perineum.  The 
triangular  unshaded  area  is  the  area  that  has  been  denuded.  All  the  sutures  have 
been  placed  but  not  tied. 

The  ends  of  the  sphincter  ani  can  be  located  by  the  little 
dimples  in  the  skin  produced  by  the  retraction  of  the  muscle. 
The  muscle  should  be  grasped  between  the  thumb  and 
fingers  of  each  hand  and  stretched  as  far  as  possible.  The 
ends  of  the  sphincter  are  exposed  by  carrying  incisions 
downward  from  the  denuded  surface  of  the  recto-vaginal 
septum  over  the  dimples  and  dissecting  back  the  skin  (Fig. 
23).  The  ends  of  the  muscle  are  caught  with  mouse-toothed 
forceps,  drawn  out,  and  sutured  together  with  fine  chromo- 
sized  catgut  (Fig.  24).  These  catgut  sutures  are  reinforced 
by    two    non-absorbable    sutures    which    are    introduced 


EECTOCELE 


61 


through  the  skin  and  through  the  ends  of  the  muscle. 
After  the  rectum  and  the  sphincter  are  closed,  the  con- 
dition present  and  the  judgment  of  the  operator  should 
decide  whether  the  remainder  of  the  perineal  repair  can 
best  be  completed  by  the  flap-splitting,  Emmet's,  or  Hegar's 
method. 


Fig.  23.  —  Operation  for  Repair  of  the  Sphincter  Ani.  First  step.  The 
dark  lines  show  the  lines  of  incision.  The  long  incision  splits  the  septum  between 
the  rectum  and  vagina.  The  short  incisions  downward  from  tins  long  incision  are 
over  the  ends  of  the  ruptured  sphincter. 


RECTOCELE 

Rectocele  is  a  prolapse  of  the  posterior  vaginal  wall  and 
the  anterior  rectal  wall  clue  to  an  injury  to  the  recto-vaginal 
septum.  It  presents  the  appearance  of  a  rounded  mass  pro- 
jecting from  the  relaxed  vaginal  outlet.  It  is  soft  and 
easily  pushed  back  by  the  examining  finger.  It  can  be 
distinguished  easily  from  a  cystocele,  which  it  resembles 
in  general  appearance  by  the  corrugations  of  the  anterior 


62  INJURIES    TO    THE    PELVIC    FLOOR 

vaginal  wall  near  the  meatus  over  the  cystocele,  and  by 
the  relation  of  the  two  to  the  vaginal  canal.  The  exam- 
ining finger  passes  into  the  vaginal  canal  above  the  recto- 
cele  but  below  the  cystocele.    Both  rectocele  and  cystocele 

are  frequently  mistaken  by 
patients  for  prolapse  of  the 
uterus. 

Treatment.  —  Any  of  the 
operations  described  for  re- 
pair of  the  perineum  will 
give  good  results  in  the  treat- 
ment of  rectocele. 


CYSTOCELE 

Cystocele  is  a  prolapse  of 
the  bladder  and  anterior 
vaginal    wall. 

Pathology.  —  Cystocele  is 
nearly    always    secondary   to 

Fig.  24.  —  Operation  for  Repair  . 

of  the  Sphincter  Ani.  Second  step,  injuries  to  the  pelvic  floor 
The  tear  in  the  rectum  has  been  closed,  received  during  labor.  These 
The  ends  of  the  sphincter  have  been    ...  -.      .         -.         ,-. 

drawn  up  and  the  catgut  sutures  to  juries  ™  a  rule  involve  the 
bring    them    together    are    shown    in   pelvic    fascia    both    anteriorly 

position.  an(j  pOSteriorly  to  the  uterus. 

It  is  very  commonly  associated  with  retrodisplacement  and 
prolapse  of  the  uterus.  When  the  bladder  prolapses,  a 
portion  of  it  drops  below  the  point  of  insertion  of  the 
urethra.  As  a  result,  these  patients  cannot  completely 
empty  the  bladder  and  many  of  them  suffer  from  a  sec- 
ondary cystitis.  The  friction  of  the  clothing  against  the 
mucous  membrane  of  the  anterior  vaginal  wall  produces  a 
thickening  of  its  epithelial  cover  and  the  formation  of 
a  horny  layer  of  epithelium  such  as  is  found  in  true  skin. 


CYSTOCELE 


G3 


In  rare  instances  primary  carcinoma  of  the  vagina  develops 
in  the  prolapsed  portion  of  the  anterior  vaginal  wall. 

Symptoms.  —  These  patients  complain  of  a  rounded 
tumor  pushing  through  the  vaginal  outlet.  The  friction  of 
the  clothing  against  the  mucous  membrane  produces  some 
discomfort.  Frequent  and  painful  urination  due  to  the 
secondary  cystitis  are  very 
constant  and  annoying 
symptoms. 

Diagnosis.  —  A  cystocele 
presents  a  rounded  mass 
projecting  through  the  re- 
laxed vaginal  outlet.  It 
apparently  increases  in  size 
when  the  bladder  is  dis- 
tended, when  the  patient  is 
on  her  feet,  or  when  there 
is  any  increase  of  intra- 
abdominal tension.  The 
corrugations  on  the  an- 
terior vaginal  wall  just  be-  Fig.  25.  —  Cystocele  and  Recto- 
low   the   meatus   are   very  CELE' 

distinct.  The  tumor  is  soft,  presents  very  little  resistance 
to  the  finger  on  examination,  and  can  be  easily  pushed  up 
out  of  view.  The  examining  finger  passes  into  the  vagina 
beneath  the  tumor.  A  curved  sound  introduced  through 
the  urethra  into  the  prolapsed  bladder  can  be  easily  felt 
through  the  anterior  vaginal  wall. 

Treatment.  —  Operation  for  the  relief  of  cystocele  is 
nearly  always  undertaken  in  connection  with  operations  for 
other  conditions,  especially  for  retrodisplacement  or  pro- 
lapse of  the  uterus. 

A  transverse  incision  is  made  in  the  mucous  membrane 
of  the  anterior  vaginal  wall  just  below  the  lowest  point  to 


64 


INJUEIES    TO    THE    PELVIC    FLOOE 


which  the  bladder  comes.  A  perpendicular  incision  is  car- 
ried from  the  middle  of  this  line  up  the  vaginal  wall  to  a 
point  near  the  meatus.  With  a  piece  of  gauze  covering 
the  forefinger  the  bladder  is  separated  from  the  uterus  and 
from  the  anterior  vaginal  wall  (Fig.  27).  The  bladder  is 
pushed  up  to  its  normal  level.    The  superfluous  vaginal  wall 


Fig.  26.  —  Thickened  Vaginal  Epithelium.  (Photomicrograph.)  Thick- 
ened vaginal  epithelium  of  this  character  is  found  in  all  cases  of  prolapse  of  the 
anterior  vaginal  wall  of  long  standing. 

on  either  side  of  the  perpendicular  incision  is  cut  away. 
One  or  two  stitches  are  then  put  in  the  upper  angle  of 
the  wound  through  the  vaginal  wall  only.  Immediately 
below  these,  two  number  three  chromosized  catgut  stitches 
are  passed  through  the  vaginal  wall  on  one  side,  then  into 
the  uterus  near  the  internal  os,  and  out  through  the  vaginal 
wall  on  the  opposite  side.  When  these  two  stitches  are  tied 
they  bring  the  vaginal  wall  and  the  uterus  in  apposition 


CYSTOCELE 


65 


and  entirely  close  up  the  space  into  which  the  bladder  had 
prolapsed.  The  remainder  of  the  wound  in  the  vaginal 
wall  is  closed  by  a  running  catgut  suture. 

A  somewhat  more  radical  procedure  is  adopted  when 
operating  upon  women  who  have  passed  the  menopause. 


Fig.  27.  —  Repair  of  Cystocele. 
First  step.  The  anterior  vaginal  wall 
has  been  opened  by  an  inverted  T- 
shaped  incision  and  the  bladder  is  sepa- 
rated from  the  uterus  and  from  the 
anterior  vaginal  wall  by  blunt  dissec- 
tion. The  dotted  lines  on  the  flaps 
indicate  the  excess  anterior  vaginal 
wall  to  be  cut  away. 


Fig.  28.  —  Repair  of 
Cystocele.  Second  step. 
The  fundus  of  the  uterus  is 
being  drawn  forward  by 
bullet  forceps. 


The  operation  is  started  in  the  way  just  described,  but 
the  dissection  is  carried  through  the  peritoneum  between 
the  bladder  and  the  uterus.  The  fundus  of  the  uterus  is 
turned  forward  (Fig.  28)  and  stitched  to  the  vaginal  wall 
high  up  (Fig.  29).  This  puts  the  bladder  on  a  plane  en- 
tirely above  the  uterus  and  effectually  prevents  a  recur- 
rence of  the  prolapse.    Without  reference  to  the  age  of  the 


66 


INJUEIES    TO    THE    PELVIC    FLOOK 


patient,  some  operators  prefer  this  more  radical  operation 
in  all  cases  in  which  the  cystocele  is  large;  but  whenever 
the  fundus  of  the  uterus  is  stitched  to  the  vaginal  wall  in 
a  patient  who  has  not  arrived  at  the  climacteric,  the  tubes 
must  be  resected  to  prevent  a  possible  pregnancy.  In  all 
cases  the  perineum  should  be  repaired. 


Fig.  29.  —  Repaik  op  Cystocele.  pIG    30. Repair   of 

Third   step.     Shows  the  methods  of  Cystocele.    Fourth  step, 

placing  sutures  to  attach  the  fundus  of  The  operation  completed, 
the  uterus  to  the  anterior  vaginal  wall. 

Many  operations  for  cystocele  have  been  proposed,  but 
any  operation  that  does  not  eliminate  the  space  between 
the  anterior  vaginal  wall  and  the  uterus  into  which  the 
bladder  prolapses  will  never  keep  the  bladder  in  its  proper 
position. 


RECTO-VAGINAL   FISTULA 

A  recto-vaginal  fistula  may  be  due  to  the  failure  of  a  com- 
plete rupture  of  the  perineum  to  unite  after  an  attempted 
repair;   or  it  may  be  due  to  the  breaking  down  of  a  malig- 


RECTO-VAGINAL    FISTULA  G7 

nant  growth  or  some  other  ulceration.  There  is  more  or 
less  escape  of  gas  from  the  rectum.  If  the  fistula  is  small 
and  the  bowels  are  constipated,  there  is  very  little  tendency 
for  the  feces  to  pass  through  it;  but  when  the  fistula  is 
large,  and  especially  if  the  bowels  are  loose,  there  is  an 
escape  of  feces  into  the  vagina. 

Treatment.  —  When  the  cause  of  a  recto-vaginal  fistula  is 
other  than  a  traumatic  one  the  cause  must  be  treated  before 
any  attempt  at  repair  is  undertaken.  In  the  traumatic 
cases  when  the  opening  is  well  above  the  sphincter  the 
edges  of  the  fistula  can  be  split  and  the  rectal  and  vaginal 
wall  sewed  up  separately.  When  the  fistula  is  very  low 
down  it  is  usually  better  to  cut  through  all  the  perineal 
tissues  up  to  the  fistula,  denude  its  edges  and  repair  the 
perineum  as  though  there  had  been  a  complete  tear  in  the 
perineum. 


CHAPTEE   VI 

UEINAEY    FISTULA 

A  fistula  is  an  abnormal  opening  between  two  natural 
cavities  of  the  body,  or  leading  from  one  of  the  natural 
cavities  of  the  body  to  the  outside.  Urinary  fistulas  con- 
sidered here  are  abnormal  openings  leading  from  some 
portion  of  the  urinary  tract  into  some  portion  of  the  genital 
canal. 

Varieties.  —  The  simplest  method  of  classifying  the  uri- 
nary fistulse  is  an  anatomical  one.  Beginning  below,  there 
is  a  urethro-vaginal,  a  vesico-vaginal,  a  vesico-utero-vaginal, 
a  vesico-uterine,  and  a  uretro-vaginal  (Fig.  31). 

Etiology.  —  Delay  in  the  descent  of  the  head  in  the  second 
stage  of  labor  is  the  most  frequent  cause  of  vesico-vaginal 
and  vesico-uterine  fistulas.  The  bladder  and  anterior  vagi- 
nal wall  or  cervix  are  caught  between  the  head  and  the 
symphysis.  The  tissues  are  crushed  until  the  blood  supply 
is  destroyed.  A  few  days  afterward  the  devitalized  tissues 
slough,  leaving  an  opening  from  the  bladder  into  the  vagina 
or  uterus.  Occasionally  in  a  rapid  labor  a  distended  pro- 
lapsed bladder  will  be  caught  between  the  descending  head 
and  the  symphysis,  and  an  opening  will  be  torn  in  it  and 
the  anterior  vaginal  wall  by  the  pressure  from  above. 

Accidental  injuries  to  the  bladder  or  one  of  the  ureters 
during  operative  work  may  result  in  a  fistula.  The  ureters 
are  more  often  injured  during  operation  than  is  the  blad- 
der. The  injuries  to  the  bladder  and  ureters  occur  most 
frequently  during  operations  for  the  removal  of  the  uterus 

68 


UKETHRO-VAGINAL    FISTULA 


GO 


for  malignant  growths,  the  reason  being  that  in  these  oper- 
ations an  attempt  is  made  to  remove  as  much  tissue  that  is 
contiguous  to  the  uterus  as  possible,  and  the  bladder  or 
ureter  is  injured  in  the  removal  of  tissue  at  some  distance 
from  the  uterus. 

An  opening  may  be  accidentally  made  in  the  urethra 
during  an  operation  for  cysts  of  the  anterior  vaginal  wall, 
or  in  draining  a  suburethral  abscess. 


Fig.  31.  —  Diagram  Showing  Location  of  Urinary  Fistula,  a,  Urethro- 
vaginal fistula;  b,  vesico- vaginal  fistula;  c,  vesico-utero-vaginal  fistula;  d,  vesico- 
uterine fistula. 


URETHRO-VAGINAL    FISTULA 

Urethro-vaginal  fistula  is  rarely  seen,  because  when  it  oc- 
curs as  the  result  of  injury  it  usually  closes  spontaneously. 

Symptoms.  —  During  urination  the  urine  instead  of  escap- 
ing from  the  meatus  escapes  through  the  opening  in  the 
anterior  vaginal  wall,  but  as  the  defect  in  the  urinary 
tract  is  below  the  sphincter  of  the  bladder,  there  is  no 
incontinence. 

Treatment.  —  The  fistula  is  exposed  by  retracting  the 
perineum.  The  edges  of  it  are  pared,  a  silver  catheter  is 
passed  into  the  urethra  to  preserve  its  calibre,  and  the 
pared  edges  are  brought  together  by  fine  interrupted 
sutures. 


70  UEINARY    FISTULA 


VESICO-VAGINAL   FISTULA 

A  vesico-vaginal  fistula  is  an  opening  from  the  bladder 
into  the  vagina.  It  is  the  most  common  form  of  all  the 
urinary  fistulae.  It  may  be  no  larger  than  a  pin-hole,  or 
the  whole  vesico-vaginal  septum  may  be  sloughed  away. 

Pathology.  —  In  exceptional  cases  there  is  a  clean  tear  in 
the  base  of  the  bladder  and  anterior  vaginal  wall.  In 
most  instances  an  area  of  pressure  necrosis  takes  place 
which  may  leave  a  very  small  opening,  or  nearly  the  whole 
vesico-vaginal  septum  may  slough  away.  The  external 
genitals  are  kept  constantly  wet  by  the  escaping  urine. 
The  urine  decomposes,  and  the  products  of  decomposition 
act  as  irritants  to  all  the  structures  with  which  they  come 
in  contact.  There  is  a  formation  of  ammonia  compounds. 
Vulvitis,  vaginitis,  and  cystitis  are  frequent  complications. 
Usually  phosphates  are  deposited  about  the  fistulous  open- 
ing. These  deposits  accumulate  particularly  in  any  ulcer- 
ated area  in  the  bladder,  in  the  fistula,  or  in  the  vagina. 

Symptoms.  —  There  is  a  continuous  dribble  of  urine  from 
the  vagina.  When  the  fistula  follows  labor  and  is  due  to 
a  tear  in  the  bladder,  the  escape  of  urine  begins  immedi- 
ately. When  it  is  due  to  the  separation  of  a  slough  from 
pressure,  the  urine  begins  to  escape  from  three  to  ten  days 
after  the  labor.  There  is  a  strong  ammoniacal  odor  due 
to  the  decomposition  of  the  urine.  The  associated  infec- 
tions of  the  vulva,  vagina,  and  bladder  cause  much  pain 
and  burning  about  the  external  genitals.  When  the  fistula 
in  the  bladder  is  a  considerable  distance  above  the  vesico- 
urethral opening  the  patient  when  in  the  erect  position  may 
retain  a  small  amount  of  urine  in  the  bladder.  In  some 
instances  a  moderate  amount  of  urine  may  be  retained 
temporarily  when  the  patient  is  recumbent. 


VESICO-VAGINAL    FISTULA  71 

Diagnosis.  —  The  opening  in  the  anterior  vaginal  wall 
can  usually  be  felt  on  making  a  digital  examination  of 
the  vagina.  When  the  fistula  is  so  small  that  it  cannot 
be  readily  detected  by  the  finger,  a  bland  colored  fluid, 
such  as  a  weak  solution  of  methyline  blue  or  milk,  may  be 
injected  into  the  bladder.  The  point  at  which  the  fluid 
escapes  into  the  vagina  will  locate  the  fistula. 

Treatment.  —  Before  an  attempt  is  made  to  repair  the 
opening  in  the  vesico-vaginal  septum,  it  is  essential  to  get 
the  tissues  in  the  region  of  the  fistula  as  free  from  infection 
and  into  as  nearly  a  normal  condition  as  possible.  The 
larger  deposits  of  phosphates  can  be  removed  mechani- 
cally. The  infected  and  ulcerated  areas  are  painted  over 
with  a  solution  of  nitrate  of  silver.  Benzoic  acid  admin- 
istered in  ten-grain  doses  every  four  hours  renders  the 
urine  acid,  stops  the  further  precipitation  of  phosphates, 
and  assists  in  the  removal  of  deposits  of  phosphates  already 
present.  It  also  exerts  a  beneficial  action  upon  the  infected 
areas  about  the  fistula. 

In  operating  for  vesico-vaginal  fistula,  one  of  two 
methods  are  used  for  paring  the  edges  of  the  fistula.  The 
edges  may  be  caught  up  by  a  tenaculum  and  a  strip  of 
mucous  membrane  surrounding  the  whole  circumference 
of  the  fistula  may  be  removed  with  scissors.  Another 
method  is  to  split  the  edges  of  the  fistula  with  a  knife 
(Fig.  32)  and  dissect  the  bladder  and  vaginal  walls  from 
each  other  for  a  half  inch  in  all  directions  surrounding 
the  fistula.  By  this  method  no  tissue  is  removed.  The 
bladder  wall  is  then  brought  together  by  fine  chromosized 
catgut,  after  which  the  vaginal  wall  is  brought  together 
by  the  same  kind  of  sutures  (Fig.  33).  In  placing  the 
sutures  in  the  bladder  wall  thej^  should  be  placed  in  such 
a  way  as  to  make  the  edges  of  the  mucous  membrane 
pouch  forward  a  little  into  the  bladder  and  not  down  into 


72 


URIXAEY    FISTULA 


the  wound.    The  stitches  in  the  vaginal  wall  must  be  placed 
so  that  the  mucous  membrane  will  not  be  inverted. 

A  soft-rubber  catheter  is  introduced  into  the  bladder  and 
fixed  by  a  loose  silk  stitch  into  the  meatus.  In  forty-eight 
hours  this  catheter  is  removed  permanently.  After  this 
the  bladder  is  catheterized  every  six  hours  until  the  patient 
is  able  to  void  urine  herself.  This  she  is  encouraged  to  do 
at  the  earliest  possible  time.  Benzoic 
acid  in  ten-grain  doses  four  times  a 
day  should  be  administered  for  a  few 
days  after  the  operation. 

VESICO-UTERO-VAGINAL 
FISTULA 

This  fistula  is  very  similar  to  the 
vesico-vaginal  fistula,  but  as  its  name 
indicates  the  opening  is  partly  through 
the  anterior  lip  of  the  cervix.  Its 
causes,  pathology,  symptoms,  and  diag- 
nosis are  practically  the  same  as  those 
of  vesico-vaginal  fistula.    In  operating 

Fig.  32.  —  Repair  of    p        .,.  ..  n    r>   i    i        -i    • 

Vesico-vaginal  Fistula.    for  thls  variety   of   fistula,   it   IS  neces- 

First  step.     Shows  the  sary  to  dissect  the  cervix  away  from 

method    of    splitting   the    the    bladder#       After    tMg    ig    done    the 
edges  of  the  fastula. 

edges  of  the  anterior  segment  of  the 
fistula  can  be  split  and  the  bladder  separated  from  the  vagi- 
nal wall  for  a  short  distance.  The  opening  in  the  blad- 
der is  then  closed  and  the  vaginal  wall  stitched  to  the 
cervix. 


VESICO-UTERINE    FISTULA 

A  vesico-uterine  fistula  is  an  opening  from  the  bladder 
into  the  cavity  of  the  uterus. 


UKETERO-VAGI^TAL    FISTULA 


73 


Symptoms.  —  The  symptoms  produced  by  vesico-uterine 
fistula  are  similar  to  those  of  vesico-vaginal  fistula.  The 
opening  in  the  bladder  is  higher  up,  and  patients  are  some- 
times able  to  retain  a  moderate  amount  of  urine  in  the 
bladder  and  in  some  cases  even  to  pass  some  through  the 
urethra.  But  as  soon  as  the  urine  reaches  the  level  of 
the  opening  it  begins  to  discharge  through  the  cervical 
canal.  The  diagnosis  is  made  by  in- 
jecting into  the  bladder  a  colored  fluid 
which  can  be  seen  to  escape  through 
the  external  os. 

Treatment.  —  A  transverse  incision  is 
made  in  the  anterior  vaginal  wall  just 
in  front  of  the  cervix.  The  dissection 
is  carried  upward  separating  the  uterus 
from  the  bladder.  This  dissection  is 
rendered  difficult  by  the  cicatricial  tis- 
sue around  the  fistula.  The  opening  in 
the  bladder  is  then  brought  together  by 
fine  chromosized  catgut  sutures  and  the 
wound  in  the  anterior  vaginal  wall  is 
closed. 


Fig.  33.  —  Repair  of 
Vesico-vaginal  Fistula. 
Second  step.  The  wall 
of  the  bladder  has  been 
brought  together  and  the 

ing  from  one  of  the  ureters  into  the  sutures  tied.   The  sutures 


URETERO-VAGINAL   FISTULA 

A  uretero-vaginal  fistula  is  an  open- 


Thev  are  usuallv  the  result  of 


for  bringing   the   vaginal 
wall  together  are  in  posi- 


vagma 

accidental  injuries  to  the  ureters  during  tion. 

an  operation. 

Symptoms  and  Diagnosis.  —  There  is  a  continuous  dribble 
of  urine  from  the  vagina.  At  the  same  time  the  bladder 
fills  from  the  uninjured  ureter  and  is  emptied  normally. 
A  colored  fluid  injected  into  the  bladder  does  not  escape 


74  UHINARY    FISTULA 

into  the  vagina.  Which  ureter  is  injured  can  usually  be 
determined  by  inspecting  the  site  of  the  flow  of  urine.  A 
uretral  catheter  will  pass  from  the  bladder  into  the  unin- 
jured ureter,  but  will  not  pass  into  the  injured  one. 

Treatment.  —  When  the  ureter  has  been  injured  very  low 
down,  it  is  sometimes  possible  by  a  vaginal  operation  to 
implant  the  broken  ureter  into  the  bladder  at  some  point 
higher  than  normal.  Ordinarily,  however,  it  is  necessary 
to  perform  an  abdominal  operation  to  join  the  two  ends 
of  the  ureter  together  or  to  implant  the  ureter  into  the 
bladder.  When  the  injury  to  the  ureter  is  a  very  recent 
one  it  may  be  possible  to  make  a  direct  uretral  anasta- 
mosis.  The  bladder  end  of  the  ureter  is  closed  at  its  outer 
extremity  by  a  ligature.  A  slit  is  then  made  in  its  side 
and  the  distal  end  of  the  ureter  is  introduced  into  this 
slit  and  secured  by  fine  sutures.  A  drain  should  be  put 
from  Douglas'  cul-de-sac  through  the  posterior  vaginal 
wall  to  relieve  any  temporary  leakage.  In  many  instances 
the  lower  fragment  of  the  ureter  is  too  short  to  use  in  this 
way. 

Frequently  in  secondary  operations,  on  account  of  ad- 
hesions and  cicatrices,  it  is  not  possible  to  find  the  lower 
fragment  of  the  ureter.  When  this  is  the  case,  or  when 
from  any  other  cause  it  is  impracticable  to  attempt  to 
unite  directly  the  separated  uretral  fragments,  the  next 
best  operation  when  it  can  be  done  is  to  implant  the  severed 
ureter  into  the  bladder  wall.  An  incision  in  the  median 
line  of  the  abdomen  long  enough  to  give  plenty  of  room 
should  be  made.  The  bladder  must  be  freed  from  all  ad- 
hesions and  made  as  mobile  as  possible.  The  severed 
ureter  is  isolated  to  a  point  above  the  brim  of  the  pelvis. 

A  sound  is  then  introduced  into  the  bladder  through  the 
urethra  and  that  point  in  the  bladder  selected  which  can 
be  brought  to  the  end  of  the  ureter  with  the  least  tension 


UKETERO-VAGINAL    FISTULA  75 

on  the  bladder  and  on  the  ureter.  A  small  opening  is  then 
made  into  the  bladder  at  this  point  and  the  end  of  the 
ureter  introduced  through  it  and  stitched  to  the  bladder 
either  by  fine  silk  or  fine  catgut.  All  raw  surfaces  should 
be  covered  over  with  peritoneum  as  far  as  possible.  A 
drain  should  be  left  in  the  pelvis  to  remove  any  leakage. 
The  abdominal  wound  is  closed  in  the  ordinary  way. 


CHAPTER   VII 

DISEASES    OF    THE    UKETHRA   AND   BLADDER 

URETHRAL    CARUNCLE 

An  urethral  caruncle  is  a  small  growth  that  occurs 
usually  in  the  floor  of  the  meatus  (Fig.  34).  Ordinarily 
it  is  pedunculated  and  grows  from  a  very  narrow  base. 
In  other  cases  its  base  spreads  out  over 
half  or  two-thirds  of  the  circumference  of 
the  meatus.  It  is  bright  red  in  color,  has 
a  very  free  blood  supply,  and  some  of 
them  are  covered  with  many  layers  of 
stratified  squamous  epithelial  cells.  Un- 
der the  microscope  many  of  them  present 
the  appearance  of  extremely  vascular 
papillomata.  In  some  the  presence  of 
glands  can  be  easily  demonstrated  (Fig. 
35).  They  grow  very  slowly,  never  at- 
tain a  very  large  size,  and  frequently 
recur  after  removal. 

Symptoms.  —  They  cause  pain  on  uri- 
nation, and  are  so  extremely  sensitive 
even  to  very  slight  pressure  that  the 
patient  has  a  great  deal  of  pain  if  the  clothing  comes  in 
contact  with  them  or  when  there  is  any  other  source  of 
irritation.  The  constant  irritation  and  pain  so  affects  the 
general  nervous  system  of  many  of  these  patients  that  they 
are  entirely  unfitted  for  the  pursuit  of  any  occupation. 

76 


"PW 


Fig.     34.  —  Ure- 
thral Caruncle. 


URETHRAL    CARUNCLE 


77 


Diagnosis.  —  The  diagnosis  is  easily  made.  A  small  red 
growth  which  is  extremely  sensitive  to  touch  is  seen  pro- 
truding from  the  meatus. 

Treatment.  —  The  treatment  consists  of  the  complete  ex- 
cision of  the  base  of  the  growth.  The  wound  is  brought 
together  by  fine  stitches.    In  some  cases  where  the  base  of 


Fig.  35.  —  Urethral  Caruncle.     (Photomicrograph.)     A  few  glands   and 
numerous  blood-vessels  are  shown.     A,  blood-vessels;  B,  glands. 


the  growth  is  broad  it  can  be  dealt  with  more  satisfactorily 
by  the  use  of  the  cautery.  These  operations  are  very  slight, 
but  on  account  of  the  extreme  sensitiveness  of  these  growths 
and  the  nervous  condition  of  the  patient  it  is  usually  best 
to  operate  under  a  general  anesthetic.  For  a  few  days 
after  the  operation  it  is  best  to  keep  the  urine  alkaline  by 
the  administration  of  potassium  acetate  or  some  similar 
salt. 


78       DISEASES    OF    THE    TTKETHKA    AND    BLADDER 


URETHRITIS 

The  term  "  urethritis  "  includes  all  forms  of  urethral 
inflammation.  Cases  of  urethritis  not  due  to  gonorrheal 
infection  are  rare.  Other  forms  of  urethritis  are  chiefly 
interesting  from  the  standpoint  of  etiology,  since  in  symp- 
toms and  treatment  they  correspond  with  some  of  the 
stages  of  the  more  common  disorder. 

The  disease  is  more  common  between  the  ages  of  puberty 
and  the  menopause,  but  is  also  seen  in  children  and  in  old 
persons.  In  the  acute  stages  there  is  usually  an  associated 
infection  of  the  vulva  and  the  vagina.  Chronic  or  sub- 
acute urethritis  is  more  frequently  seen  than  the  acute. 
This  is  largely  due  to  the  fact  that  many  patients  suffering 
from  an  acute  gonorrheal  urethritis  are  not  examined. 

Pathology.  —  In  the  acute  stage  the  anatomical  changes 
in  the  urethra  are  those  of  a  high  grade  of  inflammation. 
During  the  height  of  the  inflammatory  process  the  meatus 
is  red  and  swollen  and  covered  with  a  thin  muco-purulent 
secretion.  In  this  secretion  the  gonococci  may  be  found 
in  varying  numbers.  Sooner  or  later  the  glands  in  the 
anterior  part  of  the  urethra  become  infected  and  minute 
drops  of  pus  may  be  seen  exuding  from  the  dilated  orifices. 
Through  the  endoscope,  the  most  marked  reaction  to  the 
infection  is  observed  to  extend  a  short  distance  back  from 
the  meatus,  to  be  less  intense  near  the  middle  of  the 
urethra,  and  in  many  cases  to  resume  a  marked  intensity 
near  the  internal  orifice. 

The  inflammation  reaches  its  height  about  the  seventh 
or  eighth  day  and  then  begins  to  subside.  After  this  the 
mucosa  gradually  loses  its  intense  red  color  and  edema- 
tous appearance.  The  pus  diminishes  and  the  number  of 
gonococci  decreases.    Complete  resolution  does  not  as  a  rule 


URETHRITIS  79 

take  place  until  after  the  fourteenth  day.  If  the  inflam- 
matory process  has  been  particularly  severe,  resolution 
may  be  delayed  for  a  much  longer  period.  Complete  reso- 
lution may  not  take  place  and  the  disease  may  pass  on  into 
the  chronic  stage.  This  stage  is  characterized  by  small 
elevated  and  congested  cone-shaped  areas  that  are  sensi- 
tive and  bleed  easily.  Scattered  over  the  mucosa  small 
ulcers  may  be  seen.  The  ulcers  secrete  a  thin  muco-purulent 
material  which  is  composed  of  pus  cells,  epithelial  cells, 
and  a  few  gonococci.  These  ulcers  show  little  or  no  ten- 
dency to  heal  spontaneously  and  may  stubbornly  resist  all 
forms  of  treatment. 

The  glands  of  Skene  are  frequently  involved,  and  here 
the  disease  is  particularly  apt  to  linger  in  a  chronic  form. 
When  these  glands  have  become  infected,  pus  may  be 
milked  out  of  them  by  pressure  from  above  downwards. 
By  this  milking  process  one  or  two  drops  of  thick  pus 
may  often  be  made  to  exude  from  the  orifices  of  the  ducts 
just  inside  of  the  urethra,  giving  evidence  of  its  source 
by  adhering  to  the  side  from  which  it  was  squeezed.  Long 
after  a  gonorrheal  infection  has  apparently  subsided  a 
general  reinfection  may  occur  from  gonococci  that  have 
lingered  in  these  glands. 

Symptoms.  —  In  the  stage  of  invasion  there  is  a  slight 
tickling  and  burning  sensation  and  some  sero-mucous  dis- 
charge. As  the  inflammatory  process  increases  there  is 
a  more  or  less  burning  sensation  in  the  urethra  which  is 
very  much  increased  on  urination.  If  the  infection  in- 
volves the  outlet  of  the  urethra  from  the  bladder,  the  urina- 
tion becomes  frequent.  The  patients  will  often  hold  their 
urine  for  hours  to  escape  the  burning  and  pain  produced 
by  the  flow  of  urine  over  the  infected  mucous  membrane. 
A  slight  rise  of  temperature  may  be  noted.  When  the 
acute  stage  of  the  infection  subsides  the  urination  becomes 


80      DISEASES    OF    THE    UEETHEA    AND    BLADDER 

less  painful.  In  the  chronic  cases  there  may  be  no  dis- 
comfort or  there  may  be  a  slight  burning  on  urination. 

Diagnosis.  —  As  a  rule  the  diagnosis  is  easy.  The  ure- 
thral orifice  is  often  observed  to  be  red  and  swollen  and 
has  a  purulent  discharge  escaping  from  it.  By  inserting 
the  finger-tip  into  the  vagina  the  urethra  is  found  to  be 
swollen  and  tender,  and  pressure  from  behind  forward 
causes  pus  to  escape  from  the  meatus.  In  the  chronic  stage, 
by  examination  with  the  urethroscope  small  ulcers  or  con- 
gested areas  can  be  seen.  With  the  microscope,  pus  cells, 
epithelial  cells,  and  gonococci  are  found  in  the  discharge. 

Treatment.  —  In  the  acute  stage  of  the  disease  no  local 
treatment  should  be  given.  The  external  genitals  should 
be  bathed  frequently  with  mild  antiseptic  solutions,  such 
as  bichloride,  one  to  six  thousand,  or  a  saturated  solution 
of  boric  acid.  A  hot  sitz-bath  may  be  used.  Rest  in  bed 
is  very  desirable.  The  diet  should  be  light  and  non-stimu- 
lating. Large  quantities  of  fluids  should  be  drunk.  The 
bowels  should  be  kept  loose  with  saline  purgatives.  For 
the  burning  and  scalding  urination,  potassium  acetate  in 
twenty-grain  doses  four  times  daily  usually  gives  the 
greatest  amount  of  relief.  As  soon  as  the  inflammation 
has  somewhat  subsided,  intra-urethral  applications  of  pro- 
targol,  one  per  cent,  or  nitrate  of  silver  solution,  one  per 
cent  are  used  daily.  As  the  inflammation  further  declines 
the  strength  of  the  solution  is  increased  gradually  up  to  two 
or  three  per  cent.  Generally  under  this  treatment  the  gono- 
cocci rapidly  disappear  and  the  discharge  becomes  less. 
After  the  gonococci  have  disappeared  the  protargol  or  ni- 
trate of  silver  solutions  should  be  discontinued.  The  pro- 
cess of  healing  may  be  further  aided  by  injecting  a  mild 
solution  of  zinc  sulphate  every  third  day  until  the  mucoid 
discharge  ceases. 

In   the   chronic   stage   injections   will  not   improve   the 


SUB-URETHBAL   ABSCESS  81 

condition.  The  only  satisfactory  method  is  to  expose  the 
ulcerated  or  congested  parts  by  means  of  an  endoscope, 
and  directly  apply  to  these  infected  parts  a  solution  of 
silver  nitrate,  twenty  grains  to  the  ounce,  every  three  to 
five  days  until  the  ulcers  have  healed.  Skene 's  glands  when 
involved  should  be  emptied  daily  by  pressure  from  above 
downwards  on  each  side  of  the  urethra.  If  there  is  a 
chronic  diffuse  inflammation  about  these  tubules,  they 
should  be  opened  from  the  vaginal  side  and  the  lining- 
mucous  membrane  cauterized  with  a  stick  of  nitrate  of 
silver,  carbolic  acid,  or  the  actual  cautery. 

STRICTURE    OF    THE    URETHRA 

In  women,  stricture  of  the  urethra  following  urethritis 
is  rare.  The  symptoms  are  not  particularly  characteristic. 
There  is  usually  a  history  of  painful  urination  which  has 
extended  over  a  long  period  of  time. 

The  diagnosis  is  made  by  determining  the  calibre  of  the 
urethra  by  the  introduction  of  sounds. 

Treatment.  —  The  urethra  should  be  thoroughly  dilated 
under  an  anesthetic.  The  proper  calibre  is  afterwards 
maintained  by  the  passage  of  sounds  every  few  days  until 
the  healing  is  complete. 

SUB-URETHRAL   ABSCESS 

A  sub-urethral  abscess  is  secondary  to  an  infection  of 
the  urethra. 

Symptoms.  —  There  is  pain  in  the  neighborhood  of  the 
urethra,  and  a  sense  of  fullness  in  the  vagina.  In  some 
cases  there  is  a  marked  rise  of  temperature. 

Diagnosis.  —  If  a  metal  catheter  is  introduced  into  the 
urethra  and  one  finger  into  the  vagina,  a  fluctuating  mass 


82       DISEASES    OF    THE    UEETHEA    AND    BLADDEE 

can  be  felt  between  the  two.  The  vaginal  wall  is  apparently 
thickened.  These  signs,  with  the  history  of  the  rapid  forma- 
tion of  the  tumor  and  a  history  of  a  previous  urethritis 
serve  to  complete  the  diagnosis. 

Treatment.  —  Open  the  abscess  freely  through  the  ante- 
rior vaginal  wall  and  drain  it. 

PROLAPSE    OF   THE    URETHRA 

Prolapse  of  the  urethra  is  most  common  in  children,  but 
is  occasionally  seen  in  debilitated  women. 

Symptoms.  —  The  symptoms  are  painful  urination  and  the 
discomfort  arising  from  the  prolapsed  urethra  coming  in 
contact  with  the  clothing.  The  prolapsed  portion  presents 
a  circular  protrusion  of  a  bright  red  color  with  the  opening 
of  the  urethra  in  the  center. 

Treatment.  —  When  the  condition  is  acute  the  patient 
should  be  kept  in  bed,  the  prolapse  reduced,  and  if  a  cause 
can  be  found,  it  should  be  removed.  In  long  standing  cases 
the  protruding  portion  of  the  urethra  should  be  excised. 
The  circular  wound  is  closed  and  the  continuity  of  the 
urethra  restored  by  a  number  of  fine  interrupted  catgut 
sutures. 

OVER-DISTENTION   OF    THE    URETHRA 

Over-distention  of  the  urethra  may  result  from  too  widely 
dilating  the  urethra  in  attempting  to  remove  stones  or 
other  foreign  bodies  from  the  bladder,  but  exceptionally 
it  results  from  other  conditions. 

Symptoms.  —  When  the  sphincter  of  the  bladder  is  not 
damaged  there  is  practically  no  discomfort.  When  the  vesi- 
cle sphincter  has  been  over-distended  there  is  incontinence 
of  urine. 

Diagnosis.  —  When  there  is  incontinence  of  urine  due  to 


URETHROCELE  83 

over-distention  it  will  usually  be  found  that  the  urethra  is 
sufficiently  large  to  allow  the  introduction  of  one  finger 
or  a  sound  much  larger  than  ordinary  into  the  bladder. 
Treatment.  —  The  treatment  of  these  cases  is  extremely 
unsatisfactory,  because  the  lesion  that  gives  the  real  diffi- 
culty is  the  loss  of  contraction  in  the  vesicle  sphincter. 
Usually  it  is  not  possible  to  restore  the  sphincter.  Attempts 
have  been  made  to  reduce  the  calibre  of  the  urethra  by  dis- 
secting it  loose  nearly  its  entire  length,  giving  it  a  half 
turn  on  its  long  axis,  and  then  fixing  it  in  this  position  with 
sutures.  The  same  result  is  reached  by  resecting  the  floor 
of  the  urethra  and  suturing  it  together  over  a  small  metal 
catheter. 

URETHROCELE 

This  is  a  circular  dilatation  in  the  middle  portion  of  the 
urethra  that  is  usually  due  to  a  narrowing  of  the  meatus. 
It  presents  the  appearance  of  a  rounded  projection  in  the 
anterior  vaginal  wall.  A  sound  introduced  into  the  urethra 
through  the  meatus  can  be  felt  by  the  finger  through  the 
anterior  vaginal  wall  within  this  dilated  portion  of  the 
urethra. 

There  is  always  some  retention  of  urine,  and  as  a  result 
of  the  failure  of  drainage  a  portion  of  the  urethra  becomes 
infected.  The  mass  is  tender  on  pressure.  Very  commonly 
a  small  amount  of  pus  can  be  expressed  from  the  meatus 
by  pressure  through  the  anterior  vaginal  wall. 

Treatment.  —  If  the  obstruction  that  is  causing  the  dila- 
tation is  a  stricture  it  should  be  thoroughly  stretched.  If 
the  obstruction  is  a  new  growth  it  should  be  removed.  If 
after  the  removal  of  the  obstruction  the  patient  continues  to 
have  symptoms,  the  anterior  wall  of  the  vagina  can  be 
opened  and  the  dilated  portion  of  the  urethra  can  be 
resected. 


8-1       DISEASES    OF    THE    URETHRA    AND    BLADDER 

VESICO-URETHRAL    FISSURE 

This  is  a  small  fissure  occurring  at  the  urethro-vesicle 
junction. 

Etiology.  —  The  causes  of  it  are  not  definitely  known,  but 
are  supposed  to  be  associated  with  injuries  received  during 
labor  or  infections  of  the  urethra  and  bladder. 

Symptoms.  —  The  symptoms  are  a  constant  desire  to  uri- 
nate, extreme  tenesmus,  and  burning  pain  associated  with 
urination.  The  discomfort  is  not  relieved  by  emptying  the 
bladder. 

Diagnosis.  —  The  diagnosis  can  only  be  made  by  inspec- 
tion with  the  cystoscope. 

Treatment.  —  Dilate  the  vesical  orifice.  This  dilatation 
should  not  extend  beyond  half  an  inch  in  diameter.  Acetate 
of  potash  should  be  administered  to  render  the  urine  bland. 

EXSTROPHY    OF    THE    BLADDER 

There  are  a  number  of  congenital  defects  of  the  bladder, 
but  the  one  of  greatest  importance  on  account  of  its  relative 
frequency  is  exstrophy  of  the  bladder. 

In  this  condition  the  anterior  bladder  wall  and  its  cover- 
ings are  absent  and  the  mucous  membrane  of  the  posterior 
bladder  wall  is  exposed  and  presents  a  red,  fungous-looking 
surface.  The  orifices  of  the  ureters  can  sometimes  be  seen. 
There  being  no  anterior  bladder  wall,  there  is  necessarily 
no  reservoir  to  contain  the  urine  and  it  escapes  directly 
from  the  ureters  over  the  external  surfaces.  The  urine 
decomposes  and  produces  excoriations.  There  is  a  ten- 
dency to  the  deposit  of  phosphates. 

Treatment.  —  There  are  such  wide  variations  in  the  size 
of  the  defective  areas  that  it  is  not  possible  to  give  any 


CYSTITIS  85 

general  line  of  treatment  that  is  applicable  to  all  cases. 
Where  the  defect  is  small,  it  may  be  possible  to  reconstruct 
the  bladder  and  the  abdominal  wall  by  a  plastic  operation. 
Where  the  defect  is  so  large  that  this  cannot  be  done,  the 
entire  treatment  consists  in  palliative  measures  to  reduce 
the  inconvenience  from  the  constantly  escaping  urine. 

CYSTITIS 

Inflammation  of  the  bladder  in  women  is  an  extremely 
common  disease.  It  may  occur  either  as  an  acute  or  chronic 
condition. 

Etiology.  —  Pathogenic  bacteria  reach  the  bladder  by 
being  carried  in  on  a  catheter  more  frequently  than  in  any 
other  way.  Very  often  the  catheter  becomes  infected  by 
coming  in  contact  with  the  labia  during  its  introduction. 
Catheterization  should  always  be  done  by  sight  and  not 
by  touch.  The  catheter  should  be  sterilized  and  the  hands 
of  the  person  using  the  catheter  should  be  thoroughly 
washed.  The  vestibule  and  the  neighboring  portions  of 
the  vulva  should  be  wiped  off  with  cotton  saturated  with 
one  to  four  thousand  bichloride  of  mercury  solution.  The 
labia  minora  should  be  separated  by  the  thumb  and  fingers 
of  one  hand  and  the  catheter  introduced  into  the  urethra 
and  not  allowed  to  come  in  contact  with  the  labia.  Any 
kind  of  catheter  may  be  used,  but  a  soft-rubber  catheter 
is  generally  the  most  satisfactory. 

The  bladder  is  frequently  infected  by  direct  continuity 
from  an  infected  urethra.  The  retained  urine  in  the  pro- 
lapsed portion  of  the  bladder  when  a  cystocele  is  present 
forms  an  excellent  culture  medium  for  bacteria  and  many 
of  these  patients  suffer  from  cystitis.  Practically  the  same 
condition  exists  in  patients  who  have  had  an  over-distention 
of  the  bladder  from  any  cause.    Foreign  bodies  in  the  blad- 


86       DISEASES    OF    THE    URETHRA    AND    BLADDER 

cler  nearly  always  have  a  cystitis  associated  with  them. 
The  bladder  may  be  infected  from  the  kidney  either  when 
the  kidney  is  infected  or  by  the  healthy  kidney  allowing 
pathogenic  bacteria  to  pass  through  it  which  find  a  lodg- 
ment in  the  bladder. 

Cystitis  may  result  from  the  adhesion  of  an  infected 
Fallopian  tube  to  the  bladder  wall.  The  infection  passes 
directly  through  the  wall  of  the  tube  and  the  wall  of  the 
bladder.  This  may  happen  when  there  is  any  other  infection 
near  the  bladder.  Of  all  these  causes  the  careless  use  of 
the  catheter  is  the  most  prolific. 

Pathology.  —  The  portion  of  the  bladder  most  frequently 
infected  is  a  little  triangular  area  bounded  by  the  three 
lines  that  connect  the  orifices  of  the  ureters  and  the  vesicle 
outlet.  The  mucous  membrane  is  red  and  swollen  and 
may  be  covered  with  mucus  or  pus.  Erosions  of  the  epi- 
thelium occur  which  may  result  in  the  formation  of  ragged 
irregular  ulcers.  The  frequent  contractions  of  the  bladder 
result  in  muscular  hypertrophy.  The  bladder  capacity  may 
be  reduced  to  one  or  two  ounces. 

The  pathogenic  bacteria  most  frequently  found  are  the 
bacillus  coli  communis,  gonococcus,  and  bacillus  tubercu- 
losis. Quite  a  variety  of  other  micro-organisms  are  occa- 
sionally present.  The  gonococcus  and  bacillus  tuberculosis 
are  the  most  important,  since  these  organisms  will  attack 
the  healthy  bladder  in  the  absence  of  any  predisposing 
cause.  On  the  other  hand  the  normal  bladder  offers  so 
much  resistance  to  the  other  bacteria  that  ordinarily  they 
do  not  become  active  except  under  favorable  conditions. 

Symptoms.  —  There  is  frequent  and  painful  urination. 
The  pain  and  tenesmus  are  not  relieved  by  the  evacuation 
of  the  bladder.  In  many  cases  there  is  more  or  less  con- 
stant pain  in  the  region  of  the  bladder. 

Diagnosis.  —  There  is  usually  a  history  of  a  urethritis  or 


CYSTITIS  s: 

of  the  use  of  the  catheter.  By  bimanual  examination  the 
base  of  the  bladder  is  found  to  be  tender  and  painful  on 
pressure.  The  urine  may  be  clear,  but  is  more  frequently 
cloudy.  The  cloudiness  is  due  to  the  presence  of  either  pus, 
mucus,  blood,  or  broken-down  epithelium.  By  microscopic 
examination  all  these  may  be  found.  The  reaction  to  litmus 
is  nearly  always  acid.  Occasionally  in  the  cases  where  a 
cystocele  is  present  the  urine  may  be  alkaline  in  reaction. 
In  the  chronic  cases,  by  the  aid  of  the  cystoscope  the  in- 
fected areas  can  be  directly  inspected. 

Treatment.  —  One  of  the  most  valuable  therapeutic  agents 
in  the  treatment  of  all  forms  of  cystitis  is  water.  The 
patient  should  be  encouraged  to  drink  as  much  water  as 
possible.  Ten  grains  of  benzoic  acid  in  combination  with 
ten  grains  of  biborate  of  sodium  should  be  given  every  four 
hours.  The  value  of  benzoic  acid  in  cystitis  depends  not 
so  much  upon  its  rendering  the  urine  acid  as  upon  its  direct 
antiseptic  properties.  Other  valuable  urinary  antiseptics 
are  urotropin  and  similar  compounds.  Urotropin  is  more 
easily  administered,  but  the  results  from  benzoic  acid  are 
very  much  more  certain. 

In  the  chronic  cases  and  occasionally  in  the  acute  cases 
benefit  is  derived  by  the  irrigation  of  the  bladder  with 
normal  salt  solution  or  saturated  boracic  acid  solution. 
Many  cases  are  entirely  relieved  by  a  thorough  dilatation 
of  the  whole  length  of  the  urethra.  In  very  obstinate  cases 
the  bladder  may  be  irrigated  with  a  solution  of  one  to  two 
grains  of  nitrate  of  silver  to  the  ounce.  The  excess  should 
be  washed  out  with  plain  water  or  with  normal  salt  solu- 
tion. Localized  infections  and  ulcerated  areas  should  be 
treated  by  the  direct  application  of  a  strong  solution  of 
nitrate  of  silver  applied  through  the  cystoscope. 

In  cases  where  there  has  been  hypertrophy  of  the  blad- 
der wall  and  a  marked  contraction  of  the  bladder,  its  re- 


88       DISEASES    OF    THE    UEETHRA    AND    BLADDER 

taming  capacity  can  be  increased  by  gradual  dilatation  by 
hydrostatic  pressure.  A  catheter  is  passed  into  the  bladder. 
This  is  connected  by  a  rubber  tube  to  an  elevated  funnel. 
Normal  salt  solution  is  passed  in  through  the  funnel  until 
the  bladder  is  filled  to  a  capacity  that  gives  distinct  dis- 
comfort. After  the  bladder  has  been  kept  distended  for 
a  few  minutes  the  water  is  allowed  to  escape  and  the  process 
is  repeated.  By  keeping  this  treatment  up  daily  for  a 
considerable  length  of  time,  very  marked  gain  in  bladder 
capacity  can  be  made.  Where  other  means  of  treatment 
have  failed  an  artificial  vesico-vaginal  fistula  should  be 
made.  The  fistula  should  be  made  in  the  median  line  to 
avoid  the  orifices  of  the  ureters  and  far  enough  posteriorly 
to  avoid  the  urethral  opening.  The  incision  should  be  about 
one  inch  long.  To  keep  it  open  the  mucous  membrane  of 
the  bladder  should  be  stitched  down  to  the  mucous  mem- 
brane of  the  anterior  vaginal  wall.  After  the  cystitis  has 
subsided  this  fistula  may  be  closed. 

VESICAL   CALCULUS 

Stone  in  the  bladder  is  very  much  less  frequent  in  women 
than  in  men.  They  are  usually  of  the  phosphatic  variety, 
and  in  the  majority  of  cases  are  due  to  the  retention  in  the 
bladder  of  some  foreign  body.  Small  uric  acid  calculi  com- 
ing down  from  the  kidney  nearly  always  escape  through  the 
short  patulous  urethra.  The  formation  of  stone  sometimes 
follows  operations  for  vesico-vaginal  fistula.  In  that  case 
they  are  usually  phosphatic  stones  that  form  around  a  non- 
absorbable stitch  that  has  penetrated  the  mucous  membrane 
of  the  bladder.  They  more  commonly  result  from  the  lodg- 
ment in  the  bladder  of  some  foreign  body  that  has  been 
accidentally  introduced  through  the  urethra. 

Symptoms.  —  The  symptoms  are  those  due  to  the  associ- 


VESICAL    CALCULUS  89 

ated  cystitis.  In  exceptional  cases  there  will  be  sudden 
blocking  of  the  urine  by  the  foreign  body  obstructing  the 
urethral  outlet. 

Diagnosis.  —  The  stone  or  other  foreign  material  in  the 
bladder  can  easily  be  felt  by  bimanual  examination.  If  a 
metal  catheter  or  sound  is  introduced  into  the  bladder  it 
can  be  felt  to  strike  some  solid  body  and  a  distinct  click 
is  elicited. 

Treatment.  —  As  has  already  been  suggested,  small  stones 
in  the  bladder  usually  escape  of  their  own  accord,  or  they 
may  be  removed  by  forceps  after  a  moderate  dilatation  of 
the  urethra.  The  larger  stones  can  be  most  safely  and 
easily  removed  by  way  of  an  incision  through  the  median 
line  of  the  anterior  vaginal  wall  and  the  base  of  the  bladder. 
The  incision  should  avoid  the  ureteral  and  urethral  open- 
ings into  the  bladder.  Since  these  patients  nearly  always 
have  a  cystitis,  it  is  usually  best  to  make  no  attempt  to 
close  up  the  incision  at  the  time.  If  the  patient  is  treated 
for  the  cystitis,  usually  by  the  time  the  inflammation  in  the 
bladder  is  relieved  the  fistula  will  have  closed  of  itself. 
If  it  has  not,  it  may  be  closed  by  a  slight  plastic  operation. 


CHAPTER   VIII 

THE    UTERUS 

ANATOMY 

The  uterus  is  divided  into  a  body  and  a  cervix.  In  the 
virgin  these  are  of  about  equal  length,  but  in  women  who 
have  borne  children  the  body  is  nearly  double  the  length 
of  the  cervix. 

Body  of  the  Uterus.  —  The  body  is  pyrif  orm  in  shape  and 
somewhat  flattened  from  before  backwards.  Its  size  varies 
considerably  within  normal  limits;  ordinarily  it  is  about 
one  inch  and  a  half  long  and  about  the  same  in  breadth 
and  one  inch  in  thickness.  The  closed  end  or  fundus  of 
the  uterus  is  dome-shaped.  The  walls  are  made  up  of  a 
serous,  a  muscular,  and  a  mucous  layer.  The  serous  coat 
is  a  reflection  of  the  peritoneum  and  covers  the  entire  an- 
terior and  posterior  walls  of  the  body.  From  the  sides  it 
passes  outward  to  form  the  broad  ligaments;  behind  it 
passes  downward  over  the  supravaginal  portion  of  the 
cervix.  In  front  it  is  reflected  from  the  lower  part  of  the 
anterior  wall  upward  over  the  bladder.  The  muscular  layer 
forms  the  mass  of  the  uterine  wall.  The  fibers  run  circu- 
larly, longitudinally,  and  diagonally,  but  they  are  so  inti- 
mately intertwined  that  it  is  difficult  to  demonstrate  them. 

The  anterior  and  posterior  walls  of  the  body  of  the  uterus 
lie  in  contact  with  each  other.  The  internal  surfaces  of 
both  walls  are  triangular  in  shape.  The  base  of  the  triangle 
is  upward  and  the  angles  correspond  to  the  openings  of 

90 


ANATOMY 


91 


the  Fallopian  tubes ;  the  apex  points  downward  and  is  con- 
tinuous with  the  cervical  canal.  The  cavity  of  the  uterus 
is  lined  with  a  mucous  membrane  —  the  endometrium. 
Three  distinct  types  of  cells  are  found  in  the  endometrium. 
The  bulk  of  the  tissue  is  made  up  of  ovoid  embryonic  con- 


Fig.  36.  —  Post-menstrual  Endometrium.    (Photomicrograph.)    The  glands 
of  the  endometrium  are  narrow  and  regular  in  outline.    The  stroma  is  dense. 


nective  tissue  cells.  Just  around  the  glands  are  a  few  of 
these  cells  that  have  assumed  a  spindle  shape.  Scattered 
among  the  ovoid  cells  are  a  few  small  round  or  lymphoid 
cells.  These  round  cells  occur  either  singly  or  in  small 
definitely  outlined  groups.  The  surface  of  the  endometrium 
is  covered  with  a  single  layer  of  low  columnar  epithelium. 
The  nuclei  are  near  the  middle  of  the  cells.  Penetrating 
the  endometrium  are  numerous  tubular  glands  which  are 


92  THE    UTEEUS 

lined  with  a  single  layer  of  the  same  variety  of  epithelium 
which  is  found  on  the  surface. 

The  appearance  of  the  endometrium  varies  greatly  with 
the  different  periods  of  the  menstrual  cycle. 

Just  after  menstruation  the  glands  are  collapsed,  straight, 
and  narrow.     The  surface  epithelium  and  the  epithelium 


Fig.  37. — Pre-menstrual  Endometrium.  (Photomicrograph.)  The  glands 
are  widely  distended  and  very  irregular  in  outline.  The  stroma  is  much  less  dense 
than  in  the  post-menstrual  type. 

of  the  glands  is  low,  regular,  in  a  single  layer,  and  takes 
the  tissue  stain  evenly  and  deeply.  The  stroma  cells  are 
regular  in  size,  oval  in  shape,  and  stain  well  (Fig.  36). 

Just  before  menstruation  the  glands  are  distended  with 
mucus.  They  become  so  crooked  that  they  are  spoken  of  as 
corkscrew  glands.  The  epithelial  cells  lining  the  glands 
are  swollen  and  buckle  out  into  the  calibre  of  the  glands. 


ANATOMY 


93 


This  gives  the  appearance  that  is  called  saw-toothed  glands. 
But  with  all  these  apparent  irregularities  there  is  preserved 
a  certain  amount  of  uniformity  so  that  all  the  glands  of 
the  same  endometrium  have  a  similar  appearance.  The 
stroma  cells  are  enlarged,  more  rounded,  and  take  the 
stain  less  deeply.    This  change  in  the  stroma  cells  is  more 


Fig.  38.  —  Normal  Cervical  Glands.    (Photomicrograph.) 


marked  in  the  superficial  portion  of  the  endometrium. 
There  is  some,  though  no  very  great,  increase  in  the  small 
round  cells  in  the  stroma  (Fig.  37).  In  the  interval  be- 
tween these  two  extremes  there  is  a  gradual  change  from 
post-menstrual  type  of  endometrium  to  the  pre-menstrual 
type.  The  direct  cause  of  these  changes  in  the  endometrium 
and  the  menstrual  flow  is  in  all  probability  the  ovarian 
secretion. 


94 


THE    UTERUS 


Cervix  Uteri.  —  The  cervix  is  cylindrical,  a  little  wider  in 
the  middle  than  at  the  ends,  and  about  one  inch  and  a 
quarter  long.  The  vaginal  attachment  divides  the  cervix 
into  the  vaginal  and  supravaginal  portions.  The  cervix, 
like  the  body  of  the  uterus,  has  a  serous,  a  muscular,  and 
a  mucous  coat.  The  serous  coat  is  the  reflection  of  the 
peritoneum  which  covers  only  the  posterior  wall  of  the 
supravaginal  portion.  The  muscular  layer  consists  of  cir- 
cular, longitudinal,  and  diagonal  fibers.  At  the  internal  os 
the  circular  fibers  greatly  predominate,  forming  a  sort  of 


Fig.  39.  —  Blood  Supply  to  the  Uterus. 


sphincter.  At  the  external  os  there  are  also  many  circular 
fibers,  but  so  definite  a  sphincter  is  not  formed  as  at  the 
internal  os.  The  canal  of  the  cervix  is  fusiform,  being 
a  little  wider  in  the  middle  than  at  either  end.  Its  upper 
end  where  it  becomes  continuous  with  the  cavity  of  the 
uterus  is  known  as  the  internal  os.  The  outer  end  opening 
into  the  vagina  is  the  external  os.  The  cervical  canal  is 
lined  by  a  mucous  membrane  which  is  thrown  into  numerous 
ridges  (arbor  vitae)  and  penetrated  by  many  branched 
glands  (Fig.  38).  It  is  covered  with  a  single  layer  of 
high  columnar  epithelium  whose  nuclei  are  near  the  base 
of  the  cells.     The  glands  are  lined  by  a  single  layer  of 


ANATOMY  95 

the  same  kind  of  epithelium.  The  outer  surface  of  the 
vaginal  portion  of  the  cervix  is  covered  by  a  mucous  mem- 
brane that  is  a  continuation  of  the  mucous  membrane  of 
the  vagina  and  whose  surface  epithelium  is  of  the  same 
stratified  squamous  type  that  is  found  in  the  vagina.  Under 
normal  conditions  the  squamous  epithelium  terminates  at 


Fig.  40.  —  Lymphatics  of  the  Uterus. 

the  external  os;  but  it  is  a  stronger  growing  epithelium 
than  the  high  columnar  of  the  cervical  canal,  and  frequently 
if  the  columnar  epithelium  is  destroyed  either  by  direct 
violence  or  infection  it  is  replaced  by  squamous  epithelium. 
This  accounts  for  the  presence  of  the  squamous  epithelium 
sometimes  found  on  the  surface  of  the  lower  part  of  the 
cervical  canal. 

Blood  Supply.  —  The  blood  supply  to  the  uterus  is  from 
two  sources,  —  the  two  ovarian  arteries  and  the  two  uterine 


96  THE    UTERUS 

arteries.  The  ovarian  arteries  come  off  from  the  abdominal 
aorta  just  below  the  renal  arteries.  They  diverge  some- 
what from  each  other  as  they  descend,  and  on  reaching  the 
level  of  the  common  iliac  artery  they  turn  inward  between 
the  folds  of  the  broad  ligament.  Branches  are  given  off  to 
supply  the  Fallopian  tubes  and  ovaries.  When  they  ap- 
proach the  uterus  they  turn  downward  to  anastomose  with 
the  uterine  arteries.  Many  small  branches  are  given  off 
that  supply  the  body  of  the  uterus.  The  uterine  arteries 
rise  from  the  anterior  branches  of  the  internal  iliacs.  They 
pass  downward. and  inward  through  the  bases  of  the  broad 
ligaments  to  near  the  cervix,  and  then  upwards  to  anasto- 
mose with  the  ovarian  arteries.  They  pass  over  the  ureters 
about  half  an  inch  from  the  cervix.  Neither  the  ovarian  nor 
the  uterine  arteries  penetrate  the  walls  of  the  uterus. 

Lymphatics.  —  The  lymphatics  from  the  upper  part  of  the 
body  of  the  uterus  pass  outward  in  the  broad  ligament  fol- 
lowing the  general  course  of  the  ovarian  vessels  to  the 
lumbar  glands.  The  lymphatics  from  the  lower  part  of  the 
body  and  from  the  cervix  run  along  the  course  of  the  uterine 
artery  and  terminate  in  the  internal  iliac  glands.  A  few 
lymphatic  vessels  follow  the  round  ligaments  to  the  inguinal 
glands. 

MALFORMATIONS   OF   THE   UTERUS 

The  Fallopian  tubes,  the  uterus,  and  the  vagina  are  de- 
veloped from  the  ducts  of  Miiller.  In  early  embryonic  life 
these  two  ducts  are  entirely  separated  from  each  other,  but 
during  the  process  of  development  the  lower  portions  ap- 
proach each  other  and  fuse  together.  The  approximated 
walls  are  absorbed,  and  from  this  united  portion  the  uterus 
and  the  vagina  are  formed;  the  remaining  ununited  por- 
tions of  the  ducts  form  the  tubes.  The  malformations  of 
the  uterus  and  vagina  are  the  result  of  a  failure  of  the 


MALFORMATIONS    OF    THE    UTERUS  97 

ducts  of  Miiller  either  to  unite,  or  the  failure  of  the 
septum  to  be  absorbed  throughout  a  part  or  the  whole  of 
the  normal  segment  of  fusion.  Where  there  is  an  entire 
failure  of  fusion  and  both  ducts  develop,  the  result  is  a 
double  vagina  and  a  double  uterus  each  having  one  Fallo- 
pian tube.  When  the  absorption  of  the  partition  extends 
as  far  as  the  external  os,  the  result  is  a  normal  vagina 


Fig.  41.  —  Normal  Position  of  the  Uterus. 

and  double  uterus.  When  the  septum  is  absorbed  as  high 
as  the  internal  os,  the  result  is  a  uterus  bicornis.  When 
only  one  lateral  segment  develops  the  other  remaining  rudi- 
mentary, the  result  is  a  uterus  unicornis. 

NORMAL   POSITION    OF   THE    UTERUS 

When  a  woman  is  in  the  erect  position  with  the  bladder 
empty  the  uterus  is  curved  slightly  forward  upon  itself 
with  its  axis  nearly  horizontal.     It  has  a  wide  range  of 


98  THE    UTERUS 

normal  mobility.  The  uterus  is  maintained  in  its  position 
by  the  floor  of  the  pelvis  and  by  its  ligaments.  The  liga- 
ments are  the  two  broad,  two  round,  two  utero-sacral,  and 
two  utero-vesical.  The  broad  ligaments  are  formed  from 
the  two  layers  of  the  peritoneum  that  pass  off  from  the 
anterior  and  posterior  surfaces  of  the  uterus  to  the  sides 
of  the  pelvic  wall.  The  lower  portions  are  strengthened 
by  a  few  muscular  fibers  and  by  considerable  connective 
tissue.  The  upper  parts  have  very  little  connective  tissue. 
The  round  ligaments  are  two  cords  of  muscular  and  con- 
nective tissue  that  leave  the  uterus  just  in  front  of  the 
Fallopian  tubes,  take  a  peritoneal  covering  from  the  an- 
terior layers  of  the  broad  ligaments,  pass  out  through  the 
inguinal  canals,  and  are  lost  in  the  mons  veneris  and  the 
labia  majora.  They  diminish  in  size  as  they  recede  from 
the  uterus.  The  utero-sacral  ligaments  are  two  folds  of 
peritoneum  that  pass  downwards  from  the  uterus  forming 
the  lateral  boundaries  of  Douglas'  cul-de-sac,  and  are  at- 
tached near  the  third  sacral  vertebra.  They  have  some 
muscular  and  connective  tissue  in  their  lower  borders.  The 
utero-vesicle  ligaments  are  two  folds  of  peritoneum  that 
pass  forward  from  the  uterus  to  the  bladder. 


CHAPTER    IX 

DISPLACEMENTS    OF    THE    UTERUS 

The  uterus  may  be  displaced  forward,  backward,  down- 
ward, upward,  laterally,  or  it  may  be  inverted. 

FORWARD    DISPLACEMENTS 

Displacements  of  the  uterus  forward  are  classed  as  ante- 
versions  and  anteflexions. 

Anteversion 

In  anteversion  the  uterine  axis  is  turned  sharply  for- 
ward ;  but  when  the  uterus  is  freely  movable  and  the  bladder 
is  empty,  this  is  the  normal  position  of  the  uterus.  Even 
when  there  is  an  extrauterine  inflammatory  process,  or 
a  new  growth  that  fixes  the  uterus  definitely  in  this  position, 
the  position  itself  has  no  pathological  significance.  There- 
fore anteversion  of  the  uterus  as  a  pathological  entity  does 
not  exist.  It  is  the  associated  lesion  which  must  be  recog- 
nized and  treated. 

Anteflexion 

Anteflexion  of  the  uterus  is  the  sharp  bending  forward 
of  the  uterus  on  its  own  axis.  The  point  of  flexion  is 
usually  at  or  just  below  the  internal  os.  Anteflexion  is  a 
congenital  condition.  The  body  is  usually  small  and  poorly 
developed  and  the  cervix  is  long  and  narrow. 

99 


100  DISPLACEMENTS    OF    THE    UTERUS 

Symptoms.  —  Dysmenorrhea  and  sterility  are  the  only 
marked  symptoms  that  are  associated  with  anteflexion. 
The  pain  during  menstruation  usually  dates  back  to  the 
first  menstrual  period.  It  is  severe,  intermittent,  begins 
a  few  hours  before  the  flow  makes  its  appearance,  and  is 
usually  much  lessened  after  the  first  twenty-four  hours. 
Many  patients  are  confined  to  bed  for  the  first  day  or  two 


Fig.  42.  —  Anteflexion  op  the  Uterus. 

of  each  menstrual  period.  The  intermenstrual  period  is 
free  from  pain.  A  very  large  proportion  of  married  women 
who  are  sterile  and  who  have  had  dysmenorrhea  from  the 
time  they  first  began  to  menstruate,  have  anteflexion  of  the 
uterus. 

Diagnosis.  —  By  bimanual  examination  the  relation  of 
the  body  of  the  uterus  to  the  cervix  can  be  made  out  easily 
and  the  vaginal  finger  can  be  introduced  into  the  angle 
formed  by  the  body  and  the  cervix. 

Treatment.  —  Anteflexion  of  the  uterus  being  a  congeni- 


BACKWARD    DISPLACEMENTS  101 

tal  defect  is  not  easily  corrected.  A  number  of  opera- 
tions have  been  devised  for  the  relief  of  the  condition. 
The  wide  dilatation  of  the  cervical  canal  with  efficient  pack- 
ing gives  very  satisfactory  results.  The  dilatation  must 
be  done  slowly  and  thoroughly.  The  canal  should  be 
stretched  with  a  parallel-bar  dilator  to  a  diameter  of  about 
one  inch  and  a  quarter.  The  cervix  may  be  torn  if  too 
much  force  is  used  or  if  dilated  too  rapidly.  The 
cavity  of  the  uterus  is  then  curetted  to  clear  out  any 
mucus  that  may  have  accumulated  and  to  relieve  the  asso- 
ciated endometritis  if  one  be  present.  A  hard  roll  of  sterile 
gauze  as  large  as  can  be  pushed  through  the  internal  os 
is  introduced  and  left  in  the  uterus  for  forty-eight  hours. 
After  the  gauze  has  been  removed  from  the  cervical  canal 
a  hot  saline  douche  is  given  twice  daily  for  a  few  days.  The 
patient  is  rarely  confined  to  the  bed  more  than  four  days. 

BACKWARD   DISPLACEMENTS 

Backward  displacements  of  the  uterus  are  classified  as 
retroversions  and  retroflexions.  When  the  uterus  is  retro- 
verted  the  whole  axis  of  the  uterus  is  changed  so  that  the 
fundus  points  towards  the  sacrum  and  the  cervix  towards 
the  symphysis.  When  the  uterus  is  retro  flexed  its  axis 
is  bent  backward  upon  itself.  The  cervix  may  be  in  a  nearly 
normal  position.  The  body  lies  in  Douglas'  cul-de-sac. 
There  are  many  variations  in  degree  both  in  retroversions 
and  retroflexions.  Since  the  causes,  symptoms,  diagnosis, 
and  treatment  of  both  retroversions  and  retroflexions  are 
practically  the  same,  it  is  simpler  to  group  both  conditions 
together  and  speak  of  them  as  ret  rodisplacement  s. 

Etiology.  —  About  twenty-five  per  cent  of  all  retrodis- 
placements  of  the  uterus  are  congenital.  Among  the  more 
common   causes    of   acquired   retrodisplacements    are   in- 


102  DISPLACEMENTS    OF    THE    UTEKTTS 

creased  weight  of  the  uterus  in  the  puerperium;  over- 
distention  of  the  bladder,  especially  when  aided  by  the 
obstetric  binder;  too  long  a  retention  of  the  recumbent 
position  after  labor;  subinvolution;  injuries  to  the  pelvic 
floor ;  adhesions  due  to  salpingitis ;  fibroids  of  the  uterine 
wall;  and  cysts  of  the  ovaries.  It  is  a  common  belief  that 
retrodisplacements  frequently  result  from  falls  and  strains, 


Fig.  43.  —  Retroversion  of  the  Uterus. 

but  retrodisplacements  from  these  causes  are  certainly  very 
rare,  if  they  ever  occur. 

Pathology.  —  The  lesions  most  frequently  found  associ- 
ated with  acquired  retrodisplacements  are  metritis,  passive 
congestion  of  the  uterus,  hypertrophy  of  the  endometrium, 
ruptures  of  the  pelvic  floor,  rectocele,  cystocele,  and  re- 
laxation of  all  the  uterine  ligaments. 

Symptoms.  —  Some  retrodisplacements  give  rise  to  no 
symptoms.  Some  of  the  congenital  retroflexions  produce 
symptoms  very  similar  to  those  due  to  anteflexion.    Many 


BACKWARD    DISPLACEMENTS  103 

of  the  congenital  and  nearly  all  of  the  acquired  retrodis- 
placements  are  the  cause  of  one  or  more  of  the  following 
symptoms :  a  sense  of  weight  and  pressure  in  the  pelvis, 
backache,  occipital  headache,  disturbances  of  digestion,  con- 
stipation, frequent  urination,  dysmenorrhea,  menorrhagia, 
leucorrhea,  and  nervous  symptoms. 

The  pelvic  discomfort  and  backache  are  constant  and 


Fig.  44.  —  Retroflexion  of  the  Uterus. 

are  increased  when  the  patient  is  much  on  her  feet.  The 
occipital  headache  is  usually  associated  with  the  menstrual 
period.  It  is  often  of  great  severity.  Constipation  results 
in  the  exceptional  cases  where  the  body  of  the  uterus  falls 
against  the  rectum  and  blocks  it  mechanically.  Frequent 
urination  is  produced  by  the  cervix  pressing  the  base  of 
the  bladder  against  the  pubis.  The  dysmenorrhea  is  not  so 
marked  as  in  anteflexion,  but  the  pelvic  pain  and  the  pain 


104 


DISPLACEMENTS    OF    THE    UTERUS 


in  the  back  that  are  present  in  the  intermenstrual  period 
are  increased  in  severity  during  the  flow.  The  menstrual 
period  is  prolonged,  sometimes  increased  in  frequency,  and 
the  flow  is  more  profuse  than  normal.  Leucorrhea  is  due 
to  the  migration  of  small  round  cells  and  leucocytes  from 
the  congested  endometrium.  They  escape  through  the  epi- 
thelium of  both  the  glands  and  the  surface.  The  nervous 
symptoms  are  very  variable.     Not  infrequently  they  are 


Fig.  45.  —  Manual  Replacement  of  Retrodisplaced  Uterus.  First  step. 
The  body  of  the  uterus  is  elevated  by  pushing  it  upward  with  the  fingers  intro- 
duced into  the  vagina. 


of  such  a  character  that  they  are  mistaken  for  true  hysteria. 
Some  patients  have  no  symptoms  whatever  except  the  dis- 
turbances of  the  nervous  system. 

Diagnosis.  —  On  bimanual  examination  the  body  of  the 
uterus  is  not  found  in  its  normal  position.  If  a  retroversion 
is  present  the  cervix  will  be  found  pointing  forward,  while 
the  fundus  will  be  found  near  the  sacrum.  If  a  retroflexion 
is  present,  the  cervix  may  point  towards  the  pubis  or  it 
may  be  in  its  normal  position.     The  body  will  be  found 


BACKWAED    DISPLACEMENTS 


105 


behind  the  cervix.  There  are  very  few  pelvic  conditions 
that  render  the  diagnosis  of  uncomplicated  retrodisplace- 
ments  difficult.  Uterine  fibroids,  salpingitis,  adherent  en- 
larged ovaries  in  the  cul-de-sac,  and  some  other  conditions 
sometimes  make  it  very  difficult  to  definitely  locate  the  body 
of  the  uterus.  With  any  of  these  lesions,  whether  there  is 
a  displacement  of  the  uterus  or  not  is  a  minor  matter. 
The  primary  lesion  calls  for  the  first  consideration. 


Fig.  46.  —  Manual  Replacement  of  Retrodisplaced  Uterus.  Second 
step.  After  the  body  of  the  uterus  has  been  elevated  by  the  fingers  in  the  vagina, 
the  fingers  of  the  external  hand  are  pushed  down  behind  the  fundus. 


Treatment.  —  When  the  measures  for  the  relief  of  retro- 
displacements  are  considered  it  is  necessary  to  divide  the 
retrodisplacements  into  two  classes,  the  adherent  and  the 
non-adherent.  The  adherent  retrodisplaced  uterus  is  one 
that  is  fixed  in  its  position  by  adhesions  which  have  resulted 
from  a  pelvic  peritonitis.  These  cases  can  be  successfully 
treated  only  by  operation.  A  few  of  the  non-adherent  or 
movable  retrodisplacements  may  be  relieved  by  the  use  of 


106 


DISPLACEMENTS    OF    THE    UTEEUS 


pessaries.  The  group  of  retrodisplacements  that  gives  the 
best  results  when  treated  by  pessaries  are  the  acquired 
ones,  the  treatment  of  which  is  begun  soon  after  the  dis- 
placement has  occurred.  To  this  group  may  be  added  a 
very  few  of  the  acquired  displacements  that  are  seen  late 
and  an  occasional  congenital  one. 

Pessaries.  —  It  is  useless  to  try  to  relieve  a  retrodis- 
placement  by  the  use  of  a  pessary,  unless  the  displacement 


Fig.  47.  —  Manual  Replacement  of  Retrodisplaced  Uterus.  Third  step. 
The  tips  of  the  fingers  in  the  vagina  are  then  placed  against  the  anterior  lip  of  the 
cervix  and  it  is  pushed  backward  while  the  external  hand  presses  the  fundus  of 
the  uterus  forward. 

is  first  reduced.  It  is  often  best  to  treat  the  pelvic  con- 
gestion by  the  use  of  glycerin  tampons  before  attempting  to 
replace  the  uterus.  These  tampons,  thoroughly  saturated 
with  glycerin,  should  be  placed  in  the  vagina  every  second 
day  and  allowed  to  remain  from  twelve  to  twenty-four 
hours.  After  the  tampons  are  removed  vaginal  douches  of 
hot  normal  salt  solution  should  be  used  twice  a  day  until 
the  tampon  is  reinserted.     This  treatment  should  be  con- 


BACKWARD    DISPLACEMENTS  107 

tinued  until  the  pelvic  pain  and  backache  are  relieved  and 
the  tenderness  of  the  uterus  has  diminished  to  such  an  ex- 
tent that  the  uterus  can  be  manipulated  without  giving 
undue  pain. 

To  replace  the  uterus,  insert  two  fingers  into  the  posterior 
vaginal  fornix  and  push  the  body  of  the  uterus  as  high  as 
possible  (Fig.  45),  then  bring  the  fingers  in  front  of  the 


Fig.  48.  —  A  Pessary  in  Position. 

cervix  and  force  it  back  as  far  as  can  be  done.  At  the 
same  time  the  hand  over  the  abdomen  is  forced  down  be- 
hind the  fundus  and  it  is  pressed  forward  (Figs.  46  and 
47).  The  uterus  can  usually  be  replaced  in  this  way  with- 
out any  very  great  difficulty,  but  occasionally  it  may  be 
necessary  to  give  the  patient  an  anesthetic  to  secure  suffi- 
cient relaxation  of  the  abdominal  wall.  Instruments  es- 
pecially devised  for  the  replacement  of  the  uterus  are  to 
be  avoided  because  more  harm  than  good  is  likely  to  be 
done  by  them. 


108  DISPLACEMENTS    OF    THE    UTEKUS 

When  the  uterus  has  been  brought  into  its  normal  posi- 
tion an  Albert  Smith's  modification  of  Hodge's  pessary  is 
introduced  into  the  vagina  with  the  broad  end  behind  the 
cervix.  The  smallest  pessary  should  be  used  that  will  keep 
the  uterus  in  place.  A  pessary  does  not  keep  the  uterus  in 
position  by  directly  supporting  it  but  by  putting  the  pos- 
terior vaginal  wall  on  a  sufficient  stretch  to  prevent  the 
cervix  from  moving  forward  (Fig.  48).  Retroversions  are 
much  more  amenable  to  treatment  by  the  pessary  than  are 
retroflexions. 

The  patient  should  be  warned  against  neglecting  a  pes- 
sary by  leaving  it  in  position  too  long.  She  should  return 
to  the  physician  every  two  or  three  months  to  have  the 
pessary  removed  and  examined.  When  left  in  position  too 
long  the  pessary,  by  becoming  rough  from  the  accumulation 
of  phosphates,  will  erode  the  vagina. 

Operative  Treatment.  —  The  vast  majority  of  retrodis- 
placements  require  operative  treatment.  Such  a  large  num- 
ber of  operations  have  been  devised  for  the  relief  of  this 
condition  that  no  attempt  will  be  made  to  enumerate  them. 
Three  operations  will  be  described. 

Round  Ligament  Suspension.  —  The  abdomen  is  opened 
by  a  short  incision  in  the  median  line  just  above  the  pubes. 
The  fat  and  skin  are  dissected  off  the  sheath  of  the  rectus 
on  each  side  to  the  inguinal  canal.  A  curved  mouse-toothed 
forceps  closed  is  inserted  through  the  inguinal  canal.  The 
forceps  are  pushed  between  the  layers  of  the  broad  liga- 
ment to  within  two  inches  of  the  uterus.  The  point  of  the 
forceps  is  then  made  to  puncture  the  anterior  layer  of  the 
broad  ligament  (Fig.  49).  The  round  ligament  is  grasped 
and  the  forceps  withdrawn  bringing  with  it  a  loop  of  the 
round  ligament.  This  loop  of  the  round  ligament  is 
stitched  with  catgut  sutures  to  the  fascia.  The  sutures 
through  the  round  ligament  should  be  placed  in  such  a  way 


BACKWARD    DISPLACEMENTS 


109 


as  to  firmly  close  the  opening  made  in  the  fascia  by  the 
insertion  of  the  forceps. 

The  peritoneum  and  fascia  of  the  rectus  muscle  are  closed 
in  the  usual  way.  A  separate  fine  running  catgut  suture  is 
used  to  close  the  superficial 
fascia.  This  gives  an  addi- 
tional protection  to  the  sut- 
ured openings  in  the  inguinal 
canal.  The  skin  is  closed 
with  horse  hair. 

This  operation  is  applicable 
to  all  cases,  except  the  occa- 
sional ones  where  the  round 
ligaments  are  so  small  that 
they  are  too  weak  to  be  of 
any  practical  use. 

Gilliam  Operation.  —  The 
Gilliam  operation  is  in  prin- 
ciple the  same  as  that  of  the 
operation  just  described,  the 
difference  being  that  in  the 
Gilliam  operation  two  small 
openings  are  made  directly 
through  the  recti  muscles  on 
either  side  of  the  abdominal 
incision  and  loops  of  the  corresponding  round  liga- 
ments are  drawn  up  through  them  and  stitched  to  the 
fascia. 

Ventro-suspension. — The  abdomen  is  opened  in  the 
median  line  just  above  the  symphysis.  The  uterus  is  turned 
forward  and  the  posterior  median  portion  of  the  fundus 
is  attached  to  the  parietal  peritoneum  by  two  fine  silk 
stitches  (Fig.  50).  The  abdomen  is  closed  in  the  usual 
way.     Later  the   attachment  to   the   parietal   peritoneum 


Fig.  49.  —  Round  Ligament 
Suspension  of  the  Uterus.  The 
curved  forceps  has  been  pushed 
down  through  the  abdominal  wall 
and  between  the  layers  of  the  broad 
ligament  and  is  shown  grasping  the 
round  ligament. 


110 


DISPLACEMENTS    OF    THE    UTEEUS 


stretches  and  a  narrow  band  about  two  inches  long  reaches 
from  the  fundus  of  the  uterus  to  the  point  of  original 
attachment  to  the  parietal  peritoneum.  This  band  or  arti- 
ficial ligament  is  usually  sufficient  to  keep  the  fundus  of 
the  uterus  forward  and  at  the  same  time  allow  reasonable 
mobility  of  the  uterus.  Occasionally  the  uterus  becomes 
fixed  instead  of  suspended,  and  this  may  give  trouble  if 


Fig.  50.  —  Ventral  Suspension.  The  uterus  has  been  brought  up  to  the 
abdominal  wound  and  the  sutures  for  attaching  it  to  the  peritoneum  are  in 
position. 

the  patient  becomes  pregnant.  Quite  a  number  of  instances 
of  this  kind  have  been  recorded,  and  on  this  account  the 
operation  is  not  so  generally  used  as  it  was  a  few  years 
ago,  but  in  the  exceptional  cases  in  which  a  round  ligament 
suspension  is  not  practicable,  ventro-suspension  is  very 
useful. 

Alexander's  Operation.  —  An  incision  is  made  parallel 
to  and  just  above  the  inner  half  of  Poupart's  ligament. 
The  round  ligament  is  exposed  in  the  lower  part  of,  or  as 


DOWNWARD    DISPLACEMENTS 


111 


it  emerges  from,  the  inguinal  canal.  The  ligament  is  picked 
up  with  a  blunt  hook,  traction  is  made  upon  it  drawing  it 
out  from  the  inguinal  canal,  the  peritoneal  covering  is 
stripped  back,  and  the  ligament  is  stitched  to  the  fascia. 
The  same  procedure  is  repeated  on  the  other  side.  The 
operation  is  applicable  only  when  the  uterus  is  free  from 
adhesions. 


DOWNWARD   DISPLACEMENTS 

(Prolapse  of  the  Uterus) 

Prolapse  of  the  uterus  is  the  descent  of  the  uterus  in  the 
pelvis  below  its  normal  level.  Prolapses  are  divided  arbi- 
trarily into  three  degrees.  In  the  first 
degree  the  cervix  comes  down  to  the  peri- 
neum; in  the  second  degree  the  cervix 
projects  through  the  outlet  of  the  vagina ; 
in  the  third  degree  the  whole  uterus 
comes  to  the  outside.  Prolapse  of  the 
third  degree,  or  complete  prolapse,  is 
called  procidentia. 

Etiology.  —  In  the  majority  of  cases  a 
prolapse  of  the  uterus  is  the  result  of  a 
combination  of  a  number  of  pathological 
conditions.  The  two  main  factors  being 
increased  weight  of  the  uterus  and  failure 
of  the  uterine  supports.  The  increased 
weight  of  the  uterus  is  most  commonly 
due  to  sub-involution.  It  may  be  due  to 
fibroids  or  other  pelvic  growths.  The  failure  of  uterine  sup- 
ports is  usually  the  result  of  injuries  received  during  labor. 
The  most  important  of  these  are  the  injuries  to  the  pelvic 
floor,  and  of  secondary  importance  is  the  failure  of  involu- 
tion in  the  broad  and  round  ligaments.    When  a  prolapse 


Fig.    51.    —    Pro- 
lapse of  the  Uterus. 


112 


DISPLACEMENTS    OF    THE    UTEEUS 


occurs  in  a  nulliparous  woman  it  is  due  either  to  the  failure 
of  development  of  the  uterine  supports,  or  to  the  pressure 
downward  of  some  pelvic  or  abdominal  tumor. 

Pathology.  —  In  complete  prolapse  the  condition  is  really 
a  hernia,  the  contents  of  which  include  all  the  pelvic  struc- 
tures and  some  intestines.     This  sac  is  made  up  of  the 


Fig.  52.  —  Thickened  Epithelium  on  a  Prolapsed  Cervix. 
(Photomicrograph.) 

everted  vaginal  wall  near  the  middle  of  which  is  the  uterus. 
In  front  the  bladder  comes  down  along  with  the  anterior 
vaginal  wall.  Behind,  the  vaginal  wall  may  be  separated 
from  the  rectum,  or  the  rectal  wall  may  come  down  along 
with  the  vaginal  wall.  The  uterus  is  usually  sub-involuted ; 
very  commonly  there  are  lacerations  and  hypertrophy  of 
the  cervix.  Erosions  due  to  the  friction  against  the  clothing 
are  frequent.  The  broad  and  round  ligaments  are  relaxed, 
and  in  long  standing  cases  the  ligaments  may  be  atrophied. 


DOWNWARD    DISPLACEMENTS  113 

The  vaginal  walls  being  exposed  to  the  air  and  to  the 
friction  of  the  clothing  become  dry.  The  vaginal  epithelium 
becomes  thickened  and  acquires  a  horny  layer  (Fig.  52). 
Ulcerated  areas  on  the  vaginal  wall  are  comparatively  com- 
mon. In  rare  instances  an  epithelioma  develops  in  the  ex- 
posed mucous  membrane  of  the  vagina.  The  prolapsed  blad- 
der frequently  becomes  infected.  More  rarely  there  is  a 
catarrh  of  the  rectum,  and  in  some  instances  hard  fecal 
masses  accumulate  in  the  rectocele.  All  of  these  changes 
come  on  slowly.  The  gradual  descent  of  the  uterus  in  most 
instances  extends  over  a  number  of  years. 

Symptoms.  —  Most  of  the  symptoms  of  prolapse  of  the 
uterus  are  primarily  due  to  the  associated  lesions.  There 
is  some  pain  in  the  back  and  a  dragging  sensation  in  the 
pelvis.  This  pain  is  more  marked  in  the  minor  degrees  of 
prolapse  than  in  complete  prolapse.  Many  patients  with 
a  complete  prolapse  have  practically  no  symptoms  except 
the  discomfort  due  to  the  exposure  of  the  cervix  and  the 
vaginal  walls  to  the  friction  of  the  clothing.  Menorrhagia 
is  comparatively  common.  It  is  not  so  marked  as  in  retro- 
displacements.  This  same  group  of  cases  may  have  leucor- 
rhea.  Dysmenorrhea  is  rare.  When  a  cystitis  is  present  it 
causes  frequent  and  painful  urination,  giving  the  patient 
more  discomfort  than  any  other  one  of  the  associated 
lesions.  The  majority  of  these  patients  suffer  from  consti- 
pation due  to  the  lack  of  support  of  the  rectal  walls.  When 
there  is  an  erosion  of  the  cervix  or  the  vaginal  mucous 
membrane,  there  may  be  slight  hemorrhages  from  the  rup- 
ture of  small  vessels  in  the  eroded  area. 

Diagnosis.  —  The  diagnosis  can  usually  be  made  by  in- 
spection. By  palpation  the  body  of  the  uterus  can  be  found 
between  the  protruding  anterior  and  posterior  vaginal 
walls.  In  the  minor  degrees  of  prolapse  the  cervix  is  felt 
very  close  to  or  at  the  vaginal  outlet  and  the  body  corre- 


114  DISPLACEMENTS    OF    THE    UTEKITS 

spondingly  near.  An  hypertrophic  elongation  of  the  cervix 
may  be  mistaken  for  prolapse.  On  bimanual  examination 
the  body  of  the  uterus  will  be  felt  near  its  normal  position, 
and  the  lengthened  cervix  can  be  felt  extending  downward 
from  the  body  to  or  through  the  vaginal  outlet.    A  sound 

introduced  into  the  uterine 
canal  shows  it  to  be  much 
longer  than  normal.  Cysto- 
cele  and  rectocele  are  both 
frequently  confused  with 
prolapse  of  the  uterus  by 
the  laity.  A  cystocele  pre- 
sents a  rounded  mass  pro- 
jecting from  the  vaginal 
outlet  and  has  numerous 
transverse  ridges  in  the 
mucous  membrane.  It  is 
easily  pushed  back;  the  ex- 
amining finger  passes  under 
it.     A  rectocele  presents  a 

Fig.  53.  —  Operation  for  Prolapse 

of  the  Uterus.     First  step.    The  cervix  Smooth   rounded   mass   prO- 

has  been  amputated  by  the  method  shown  -jecting  from  the  vaginal 
in  Figs.  57,  58,  and  59.     The  bladder  has  ,,    ,     ,,  -    •        c 

been  separated  from  the  anterior  vaginal  0utlet5  the  examining  finger 

wall  and  from  the  uterus  as  is  shown  in  passes   Over  it.      The  finger 

Fig.  27.  The  dotted  lines  indicate  the  introduced  into  the  rectum 
excess  anterior  vaginal  wall  to  be  removed. 

will  enter  the  protruding 
mass.  In  both  cystocele  and  rectocele  the  uterus  can  be  felt 
above  the  protruding  mass. 

Treatment.  —  There  are  relatively  few  cases  of  prolapse 
of  the  uterus  that  can  be  treated  satisfactorily  with  pes- 
saries. In  some  of  the  minor  degrees  of  prolapse,  if  the 
patient  is  seen  before  the  prolapse  has  been  present  too 
long  the  wearing  of  a  pessary  may  keep  the  uterus  in  its 
normal  position  until  involution  in  the  uterus  and  in  the 


DOWNWARD    DISPLACEMENTS 


115 


ligaments  takes  place,  after  which  the  pessary  may  be  dis- 
pensed with.  In  patients  who  are  advanced  in  years,  or 
who  on  account  of  some  other  reason  are  not  good  subjects 
for  operation,  a  plain  hard-rubber  ring  pessary  can  be  used. 
Pessaries  cannot  be  used 
satisfactorily  in  any  case  un- 
less there  is  a  fairly  good 
pelvic  floor.  Numerous  oper- 
ations have  been  devised  for 
the  relief  of  prolapse.  In  the 
minor  degrees  of  prolapse  all 
that  is  necessary  usually  is 
to  repair  the  injuries  to  the 
pelvic  floor.  At  the  time  this 
repair  is  made  the  uterus 
should  be  curetted  and  any 
lacerations  of  the  cervix  re- 
paired. The  repair  of  the 
cervix  and  the  curettement 
promote    the    involution    of 


Fig.  54.  —  Operation  for  Prolapse 
of  the  Uterus.     Second  step.    Sutures 
the    uterus    which    has    been  to   attach  the  fundus   of  the  uterus  to 

one    of    the    causes    of    the  the.anterior  vaginal  wal1  are  shown  in 

position. 

prolapse. 

The  operative  procedures  for  the  restoration  of  a  com- 
pletely prolapsed  uterus  include  curettement,  amputation 
of  the  cervix,  fixation  of  the  body  of  the  uterus  forward, 
and  repair  of  the  perineum.  The  first  step  in  the  operation 
is  the  dilatation  and  curettement  of  the  uterus.  A  circular 
incision  is  then  made  around  the  cervix  through  the  mucous 
membrane  and  a  cuff  of  the  vaginal  mucous  membrane  is 
dissected  back  from  the  cervix.  The  cervix  is  amputated  at 
a  point  as  high  as  is  desired.  A  strong  catgut  ligature  is 
passed  through  each  side  of  the  cervical  stump  and  tied 
tightly  to  prevent  any  hemorrhage  from  the  lateral  cervical 


116  DISPLACEMENTS    OF    THE    UTERUS 

vessels  (Figs.  57,  58,  59,  60).  A  perpendicular  incision  is 
then  earried  up  in  the  median  line  of  the  anterior  vaginal 
wall  from  the  circular  incision  nearly  to  the  meatus.  With 
a  piece  of  gauze  over  the  forefinger  the  bladder  is  dissected 
away  from  the  uterus  and  away  from  the  anterior  vaginal 
wall  (Fig.  53).  The  peritoneum  is  opened  just  in  front  of 
the  uterus.  The  fundus  of  the  uterus  is  brought  out  through 
this  opening.  The  superfluous  anterior  vaginal  wall  is  cut 
away  on  either  side  of  the  perpendicular  incision.  If  the 
patient  has  not  arrived  at  the  menopause  the  tubes  should 
either  be  removed  or  resected.  The  fundus  of  the  uterus 
is  then  stitched  to  the  anterior  vaginal  wall  just  beneath 
the  bladder  (Fig.  54).  The  remainder  of  the  incision  in  the 
anterior  vaginal  wall  is  closed.  The  vaginal  flap  around  the 
cervix  is  stitched  to  the  cervical  endometrium  to  preserve 
the  cervical  canal.  The  perineum  is  then  repaired  by  any 
method  of  choice. 


LATERAL   DISPLACEMENTS 

The  uterus  may  be  displaced  laterally  when  there  is  an 
extreme  relaxation  of  the  broad  ligaments  with  a  loss  of 
tone  in  the  muscular  wall  of  the  uterus.  When  these  con- 
ditions are  present  a  retroflexion  of  the  uterus  usually 
occurs;  but  the  fundus  may  be  turned  to  either  side.  The 
diagnosis  and  treatment  for  this  form  of  lateral  deviation 
would  be  the  same  as  for  a  retrodisplacement  with  similar 
associated  pathological  lesions.  The  uterus  may  be  pushed 
to  one  side  or  the  other  in  the  pelvis  by  tumors,  or  it  may 
be  dragged  to  one  side  by  cicatrices  in  the  broad  ligament. 
Bad  tears  received  during  labor  starting  in  the  cervix  and 
extending  out  into  the  lateral  vaginal  wall  may  leave  a 
cicatrix  which  will  draw  the  cervix  firmly  over  to  the 
injured  side.    When  the  lateral  displacement  is  due  either 


INVERSION    OF    THE    UTERUS  117 

to   tumors   or  cicatrices   the   treatment  is   to  be   directed 
towards  relieving  the  cause  of  the  displacement. 


UPWARD    DISPLACEMENTS 

Upward  displacement  of  the  uterus  may  be  due  to  tumors 
in  the  pelvis  pushing  the  uterus  up,  or  in  exceptional  cases 
due  to  the  contraction  of  adhesions  drawing  the  uterus 
higher  than  its  normal  level. 


INVERSION   OF   THE   UTERUS 

Inversion  of  the  uterus  is  a  turning  of  the  uterus  inside 
out.  The  inversion  is  usually  not  complete.  The  body  of 
the  uterus  comes  down  through  the  cervix  and  projects 
as  a  rounded  tumor  through  the  external  os  into  the 
vagina. 

Etiology.  —  This  condition  is  nearly  always  brought  about 
by  an  unusual  degree  Of  relaxation  of  the  uterus  after  the 
second  stage  of  labor  is  completed.  It  may  be  caused 
directly  by  strong  traction  on  the  cord  when  the  uterus 
is  relaxed  in  efforts  to  deliver  the  placenta,  or  the  fundus 
may  be  pushed  down  through  the  internal  os  by  too  strong 
pressure  over  the  abdomen  during  the  period  of  relaxation. 
Submucous  fibroids  that  have  their  origin  near  the  fundus 
of  the  uterus  may  drag  the  fundus  down  and  cause 
inversion. 

Symptoms.  —  The  earlier  symptoms  are  hemorrhage  and 
pain.  The  hemorrhage  in  some  of  these  cases  is  very  severe 
and  may  cause  a  fatal  termination.  Pain  is  due  to  the  con- 
traction of  the  uninverted  portion.  In  the  cases  of  longer 
standing  the  hemorrhage  becomes  less,  but  there  is  usually 
in  all  cases  a  menorrhagia.    The  pain  gradually  decreases 


118  DISPLACEMENTS    OP    THE    UTEEUS 

and  the  patient's  discomforts  are  produced  mainly  by  the 
tumor  in  the  vagina. 

Diagnosis.  —  The  history  indicates  that  the  trouble  began 
immediately  after  the  last  labor.  On  vaginal  examination 
a  rounded  mass  is  felt  in  the  vagina,  the  highest  portion 
of  which  is  surrounded  by  a  definite  ring.  This  ring  is  the 
dilated  external  os.  On  bimanual  examination  the  body  of 
the  uterus  is  found  to  be  absent  from  its  normal  position. 
In  some  instances  when  the  abdominal  walls  are  thin,  a 
cup-shaped  depression  can  be  made  out  in  the  upper  pole 
of  the  pelvic  tumor.  This  depression  is  the  concavity  left 
by  the  disappearance  of  the  body  through  the  cervical  canal. 
On  inspection  the  openings  of  the  Fallopian  tubes  at  the 
lateral  angles  at  the  base  of  the  tumor  may  be  found.  On 
attempting  to  introduce  a  sound  through  the  external  os, 
it  will  be  found  to  pass  only  a  short  distance,  but  the  depth 
to  which  it  can  be  passed  is  the  same  on  all  sides  of  the 
tumor.  A  fibroid  polypus  projecting  through  the  external 
os  resembles  very  closely  an  inverted  uterus.  The  symp- 
toms produced  by  it  do  not  date  from  a  labor.  On  bimanual 
examination  the  body  of  the  uterus  can  be  felt  above 
the  projecting  tumor.  On  inspection  the  openings  of  the 
Fallopian  tubes  are  seen  to  be  absent.  A  sound  inserted 
through  the  external  os  goes  up  the  full  depth  of  the 
uterus. 

Prophylaxis.  —  Since  inversion  of  the  uterus  in  most  in- 
stances is  caused  by  misdirected  efforts  in  the  extraction 
of  the  placenta,  the  traction  on  the  cord  and  pressure  over 
the  fundus  of  the  uterus  in  the  interval  between  uterine 
contractions  should  be  avoided. 

Treatment.  —  In  the  acute  cases  the  uterus  can  usually  be 
returned  to  its  proper  position  by  making  direct  pressure 
upon  the  inverted  fundus  with  the  fingers  or  with  the 
fist.     After  the  uterus  is  restored  to  its  normal  position 


INVERSION    OF    THE    UTERUS  119 

the  cavity  should  be  packed  with  sterile  gauze  until  firm 
uterine  contractions  take  place. 

In  the  long  standing  cases  the  most  satisfactory  method 
is  to  split  the  binding  ring  of  the  cervix  either  anteriorly 
or  posteriorly,  or  both.  Then  push  the  fundus  of  the  uterus 
upwards  to  its  normal  position.  Close  the  incisions  and 
pack  the  uterine  cavity  with  sterile  gauze.  In  exceptional 
cases  where  there  are  many  adhesions  due  to  a  former 
infection,  it  may  be  necessary  to  do  a  vaginal  hysterectomy. 


CHAPTER   X 

DISEASES    OF    THE    CEEVIX 

LACERATION   OF   THE   CERVIX 

Some  laceration  of  the  cervix  occurs  in  nearly  all  labors. 
The  great  majority  of  these  lacerations  are  of  a  minor 
degree  and  are  of  little  or  no  pathological  importance. 
They  heal  spontaneously  and  give  rise  to  no  symptoms  and 
require  no  treatment. 

Etiology.  —  The  direct  causes  of  the  more  severe  tears 
are  the  application  of  the  obstetric  forceps  before  the  cervix 
is  sufficiently  dilated,  forcible  manual  or  instrumental  dila- 
tation of  the  cervix,  premature  rupture  of  the  membranes, 
and  excessive  uterine  contractions.  The  rapid  deliveries 
done  for  placenta  previa  and  eclampsia  are  fruitful  sources 
of  lacerations  of  the  cervix. 

Pathology.  —  Bilateral  tears  of  the  cervix  are  the  most 
common.  As  a  rule  the  deeper  tears  are  on  the  left  side. 
In  women  who  have  borne  many  children  and  more  rarely 
in  those  who  have  had  only  one  child,  stellate  tears  are 
found.  A  tear  may  extend  out  into  the  vagina  and  a 
contracting  scar  resulting  from  a  vaginal  tear  may  drag 
the  cervix  towards  the  lateral  pelvic  wall  and  limit  its 
mobility. 

The  cases  of  laceration  of  the  cervix  of  long  standing 
that  are  of  clinical  importance  have  associated  with  them 
either  subinvolution  of  the  uterus ;  infection  of  the  cervical 
endometrium;    erosions,  eversion,  or  cystic  degeneration 

120 


LACERATION    OF    THE    CERVIX  121 

of  the  cervix;  or  masses  of  scar  tissue  in  the  line  of 
attempted  union.  Any  one  or  all  of  these  lesions  may  be 
present.  The  masses  of  hard  cicatricial  tissue  which  are 
the  result  of  nature's  attempt  to  repair  the  injury  have 
been  considered  the  most  important  of  these  lesions,  but 
their  significance  has  probably  been  overestimated. 

Symptoms.  —  At  the  time  the  laceration  occurs,  there  is 
sometimes  a  severe  hemorrhage  from  it.  This  hemorrhage 
can  usually  be  distinguished  from  an  ordinary  post-partum 
hemorrhage  due  to  relaxation  of  the  uterus,  by  the  fact 
that  it  continues  after  the  uterus  is  firmly  contracted  and 
consists  of  a  small  continuous  stream  of  blood. 

In  cases  of  long  standing  the  symptoms  are  due  to  the 
associated  lesions  rather  than  to  the  laceration  itself.  Sub- 
involution causes  backache  and  a  sense  of  dragging  and 
weight  in  the  pelvis.  The  infection  of  the  cervical  endo- 
metrium and  cicatrices  give  rise  to  pains  in  the  left  iliac 
region.  The  cervical  disease  constantly  irritating  the  gen- 
eral nervous  system  causes  reflex  pains  in  the  various 
parts  of  the  body  and  sometimes  symptoms  of  hysteria. 
The  infection  of  the  cervical  endometrium  and  erosion  of 
the  cervix  cause  leucorrhea.  Sterility  is  not  uncommon, 
and  when  there  are  deep  lacerations  in  the  cervix  repeated 
abortions  sometimes  occur.  So  long  as  the  lesions  present 
do  not  involve  the  body  of  the  uterus  there  is  neither  dys- 
menorrhea nor  menorrhagia. 

Diagnosis.  —  Diagnosis  is  readily  made  by  vaginal  touch. 
The  absence  of  the  smooth  rounded  vaginal  portion  of  the 
cervix  with  its  nearly  circular  opening  is  noted.  In  the 
bilateral  lacerations  the  finger  readily  recognizes  the  cleft 
in  the  cervix  and  the  widely  separated  lips.  When  there 
is  much  eversion  the  end  of  the  cervix  instead  of  being 
rounded  presents  an  oval  flattened  surface,  the  long  diam- 
eter of  which  runs  antero-posteriorly.    An  eroded  area  has 


122 


DISEASES    OE    THE    CERVIX 


a  soft  velvety  feel.    In  cystic  degeneration  nodular  masses 
can  usually  be  felt  on  the  surface. 

Treatment.  —  The  hemorrhage  occurring  from  laceration 

of  the  cervix  immediately  after  labor  is  best  controlled  by 

exposing  the  cervix  and  bringing  the  tear  together  with  a 

few   deep   sutures.     The  results   secured 

from  these  immediate  repairs  of  the  cervix 

are  excellent. 

In  the  cases  of  long  standing  the  local 
conditions  can  be  improved  and  the  symp- 
toms temporarily  relieved  by  puncturing 
the  Nabothian  follicles  and  painting  the 
erosions  with  Churchill's  tincture  of 
iodine.  Glycerin  tampons  and  hot  vagi- 
nal douches  are  useful.  The  iodine  appli- 
cations should  be  made  and  the  glycerin 
tampons  should  be  introduced  into  the 
vagina  two  or  three  times  a  week.  A 
vaginal  douche  may  be  used  twice  daily 
after  the  tampon  has  been  removed.  The 
relief  which  the  patient  gets  from  this 
treatment  very  soon  disappears  when  the 
treatment  is  discontinued.  Its  principal 
value  therefore  is  as  a  preparatory  meas- 
ure before  operation. 

The  ordinary  bilateral  tear  in  the  cervix 
is  repaired  as  follows:  The  patient  is  put 
in  the  lithotomy  position.  A  speculum  is 
introduced  to  retract  the  perineum  and  ex- 
Both  the  anterior  and  posterior  lips  are 
seized  by  bullet  forceps  and  the  cervix  drawn  downward. 
The  cervix  is  dilated,  curetted,  and  wiped  out  with  sterile 
gauze.  The  edges  of  the  tear  may  be  denuded  either  with  a 
knife  or  with  scissors.  A  strip  of  endometrium  about  a  quar- 


Fig.  55.  —  La- 
ceration OP  THE 
Cervix.  The  strips 
of  mucous  mem- 
brane between  the 
dotted  lines  on  the 
anterior  and  pos- 
terior lips  must  be 
left  in  repairing  the 
cervix  to  preserve 
the  continuity  of  the 
cervical  canal. 

pose  the  cervix. 


LACERATION    OF    THE    CEEVIX 


123 


ter  of  an  inch  wide  must  be  preserved  both  on  the  anterior 
and  posterior  lips  to  line  the  cervical  canal  through  the 
repaired  portion  of  the  cervix.  This  strip  should  be 
slightly  wider  at  its  outer  end  than  it  is  above  (Fig.  55). 
Any  nodules  of  cicatricial  tissue  that  remain  after  the  first 
denudation  can  be  felt  by  the  finger  and  must  be  completely 


Fig.  56.  —  Repair  op  Lacera- 
tion of  the  Cervix.  The  angles 
in  the  cervical  wound  have  been 
denuded  and  the  sutures  of  one 
side  are  in  position. 


Fig.  57.  —  Amputation  of  the 
Cervix.  First  step.  Shows  the 
method  of  making  a  circular  incision 
around  the  cervix. 


removed.  The  stitches  should  be  introduced  from  above 
downward.  The  highest  stitch  on  each  side  should  be  tied 
rather  tightly  to  control  bleeding.  Usually  three  stitches 
on  each  side  are  enough  to  bring  the  parts  evenly  together 
(Fig.  56).  A  great  variety  of  suture  material  is  used  by 
different  operators;  silkworm-gut,  silk,  celluloid,  and  chro- 
mosized  catgut.  If  a  perineal  repair  is  done  at  the  same 
time  catgut  should  be  used  in  the  cervix.     Non-absorbable 


124 


DISEASES    OF    THE    CERVIX 


sutures  should  remain  about  ten  days,  though  no  harm  is 
done  if  they  are  left  considerably  longer. 

Where  there  have  been  numerous  tears  and  the  formation 
of  much  cicatricial  tissue,  it  may  not  be  practical  to  repair 
the  cervix  as  described  above.  These  cases  are  best  treated 
by  amputation  of  the  cervix.    In  doing  an  amputation  the 


Fig.  58.  —  Amputation  of  the 
Cervix.  Second  step.  Shows  the 
method  of  separating  the  vaginal  wall 
from  the  cervix. 


Fig.  59.  —  Amputation  of  the 
Cervix.    Third  step. 


preliminary  steps  are  the  same  as  for  a  cervical  repair. 
When  the  curettement  is  finished  the  cervix  is  split  on  each 
side  as  far  as  the  cicatricial  tissue  extends.  The  anterior 
and  posterior  lips  are  then  amputated  by  wedge-shaped 
incisions.  This  removes  the  scar  tissue  but  leaves  the 
mucous  membrane  of  the  cervical  canal  and  the  mucous 
membrane  on  the  outer  side  of  the  cervix.  The  flaps  are 
brought  together  forming  a  new  external  os.  The  sides  of 
the  incision  are  closed  by  one  or  two  stitches. 


LACERATION    OF    THE    CERVIX 


125 


Another  method  of  amputation  that  gives  very  good  re- 
sults, and  is  applicable  to  many  other  conditions,  is 
performed  as  follows:  Make  a  cir- 
cular incision  through  the  mucous 
membrane  around  the  cervix  (Fig. 
57) ;  dissect  back  a  cuff  of  the  vagi- 
nal wall  to  a  point  on  the  cervix 
just  above  the  scar  tissue  (Fig.  58) ; 
amputate  the  cervix  by  a  transverse 
incision  (Fig.  59) ;  tie  off  the  arteries 
on  both  sides  of  the  cervix,  including 
some  of  the  cervical  tissue  in  the 
ligature;  stitch  the  anterior  median 
portion  of  the  vaginal  cuff  to  the 
cervical  endometrium  with  two  or 
three  stitches;  stitch  the  posterior 
median  portion  of  the  vaginal  cuff 
to  the  endometrium  in  the  same  way. 
The  remainder  of  the  wound  in  the 
vaginal  wall  is  closed  over  the  end 
of  the  cervical  stump  (Fig.  60). 

After-treatment.  —  Unless  there 
are  some  special  conditions  demand- 
ing it,  there  is  no  occasion  for  the 
patient  to  remain  in  bed  after  opera- 
tion more  than  a  few  days.  After  a 
week  has  elapsed  a  vaginal  douche  of 
normal  salt  solution  or  a  very  weak 
solution  of  bichloride  of  mercury  can 
be  used  once  daily,  but  the  essential 
part  of  the  after-treatment  is  not  to  interfere  with 
the  local  healing  by  the  use  of  meddlesome  douches  and 
applications. 


Fig.  60.  —  Amputation 
of  the  Cervix.  Fourth 
step.  Suture  a  is  placed  and 
tied  tightly  to  control  the 
hemorrhage  from  a  small 
vessel  that  runs  just  external 
to  the  cervix  and  several 
small  vessels  within  the  cer- 
vical wall.  Sutures  b,  b  at- 
tach the  flap  of  the  anterior 
vaginal  wall  to  the  endome- 
trium. Sutures  c,  c  attach 
the  flap  of  the  posterior  va- 
ginal wall  to  the  endome- 
trium. Sutures  d,  d  close  the 
remaining  gap  in  the  vaginal 
wall  on  one  side. 


126 


DISEASES    OF    THE    CERVIX 


ENDOCERVICITIS 

(Cervical  Endometritis) 

Endocervicitis  is  an  inflammation  of  the  mucous  mem- 
brane lining  the  cervical  canal.  Both  acute  and  chronic 
inflammations  of  the  cervical  mucous 
membrane  occur.  The  acute  form  is 
always  so  overshadowed  by  the  asso- 
ciated infections  of  neighboring  tissues 
that  there  is  no  occasion  to  consider  it 
as  a  clinical  entity.  Chronic  endocer- 
vicitis as  a  distinct  disease  is  met  with 
frequently. 

Etiology.  —  Laceration  of  the  cervix 

favors  the  chances  of  infection.     Many 

of   the   cases    are   due   to   infection  by 

gonococci.    A  large  proportion  of  cases 

are  classified  as  catarrhal  because  it  is 

difficult    or    impossible    to    isolate    the 

micro-organism  causing  them. 

Fig.  61.  --Amputa-      Pathology.  —  The     glands     becoming 

tion  of  the  Cervix,  infected    throw    off    a    profuse    thick, 

Fifth  step.     Operation  tenacious  secretion  that  blocks  up  the 

completed. 

cervical  canal.  If  the  duct  of  a  gland 
becomes  occluded,  a  small  retention  cyst  is  formed.  These 
are  called  Nabothian  follicles.  When  they  are  numerous 
the  condition  is  spoken  of  as  cystic  degeneration  of  the 
cervix.  The  contents  of  these  cysts  is  clear,  thick,  and 
tenacious.  On  microscopical  examination  the  glands  are 
seen  to  be  dilated  and  filled  with  mucus  and  lined  by  a 
single  layer  of  epithelium.  If  the  outlet  of  the  gland  has 
become  occluded,  the  epithelial  lining  of  the  gland  is 
thinned  out  from  the  pressure  of  the  accumulated  fluid. 


END0CERVICIT1S  127 

There  is  much  small  round-cell  infiltration  in  the 
stroma. 

Symptoms.  —  A  vaginal  discharge  that  is  clear  in  color 
and  thick  and  tenacious  in  consistence,  a  sense  of  dragging 
weight  in  the  pelvis,  pain  in  the  left  iliac  region,  and  ster- 
ility are  the  usual  symptoms  present. 

Diagnosis.  —  On  vaginal  examination  the  cervix  is  usu- 
ally found  to  be  enlarged  and  frequently  nodular  on  ac- 
count of  the  distended  glands.  When  there  is  an  associated 
cervical  erosion  the  affected  area  has  a  velvety  feel  to  the 
finger.  Pressing  the  cervix  between  the  fingers  of  the  in- 
ternal and  external  hand  in  a  bimanual  examination  gives 
pain.  On  inspection  a  plug  of  tenacious  mucus  may  be 
found  in  the  cervical  canal.  The  area  around  the  external 
os  is  reddened  and  the  Nabothian  follicles  may  be  seen. 

Treatment.  —  In  the  cases  of  gonorrheal  infection  the 
most  satisfactory  results  are  obtained  by  the  use  of  glycerin 
tampons.  The  tampons  should  be  inserted  every  second  or 
third  day  and  allowed  to  remain  twenty-four  hours.  Hot 
vaginal  douches  of  normal  salt  solution  should  be  used  night 
and  morning  after  the  tampon  is  removed.  No  applications 
should  be  made  to  the  cervical  canal  on  account  of  the  dan- 
ger of  carrying  the  infection  to  the  cavity  of  the  uterus 
whence  it  quickly  extends  to  the  tubes. 

In  cases  not  due  to  gonorrheal  infection  the  Nabothian 
follicles  may  be  punctured.  The  cervical  canal  can  be 
painted  with  Churchill's  tincture  of  iodine  and  glycerin 
tampons  and  douches  used.  If  the  disease  persists  after 
the  above  treatment  has  been  faithfully  carried  out  the 
uterus  should  be  curetted  or  an  amputation  of  the  cervix 
done. 


128 


DISEASES    OF    THE    CEKVIX 


EROSION    OF    THE    CERVIX 

As  a  result  of  maceration  in  the  discharges  from  an  endo- 
cervicitis  there  is  frequently  a  loss  of  a  part  of  the  columnar 
epithelium  in  the  lower  portion  of  the  cervical  canal  and 
a  portion  of  the  squamous  epithelium  just  outside  the  ex- 
ternal os.     This  area  on  the  vaginal 
portion  of  the  cervix  may  vary  in  size 
from  a  small  ring  surrounding  the  ex- 
ternal os  to  the  size  of  the  end  of  the 
cervix.      On  inspection  it   presents   a 
bright  red  color.    On  vaginal  examina- 
tion it  feels  to  the  examining  finger 
like  a  piece  of  velvet.     On  microscop- 
ical examination  an  area  can  be  seen 
where  there  is  no  epithelium  (Fig.  63). 
When  the  process  of  recovery  is  partial 
it  will  be  seen  that  the  squamous  epi- 
thelium has   a   tendency  not  only  to 
cover  over  the  area  from  which  it  has 
temporarily  disappeared,  but  also  to  re- 
place the  eroded  columnar  epithelium. 
As  a  result  of  this,  areas  can  be  seen, 
the  surface  of  which  is  covered  with 
stratified  squamous  epithelium  and  in  the  deeper  parts  are 
the  remains  of  cervical  glands,  the  ducts  of  which  have  been 
destroyed  in  the  process  of  erosion,  and  the  space  closed  over 
in  the  process  of  healing.    These  closed-over  glands  fill  up 
slowly  with  their  own  secretion,  and  form  the  little  cysts 
frequently  seen  about  the  external  os  and  known  as  the 
NabotJiian  follicles.    Sometimes  the  covering  to  these  closed 
glands  is  very  thin,  and,  as  the  gland  fills  up,  it  projects 
in  the  form  of  a  little  polypus  just  at  or  within  the  external 
os.    These  are  the  so-called  mucous  polypi.     The  mucous 


Fig.  62.  —  Erosion  of 
the  Cervix. 


CYSTIC    DEGENERATION    OF    THE    CERVIX        120 

polypi  have  a  smooth  surface.  They  cause  leucorrhea 
and  sometimes  more  or  less  dribbling  of  blood  from  the 
cervix. 

Treatment.  —  Treatment  of  erosion  of  the  cervix  involves 
the  treatment  of  the  cause  of  the  cervical  discharge  pro- 
ducing the  erosion.    The  Nabothian  follicles  may  be  punc- 


Fig.  63.  —  Erosion  of  the  Cervix.  (Photomicrograph.)  There  is  an 
absence  of  epithelium  on  the  surface.  Some  of  the  cervical  glands  are 
dilated. 

tured  and  their  contents  evacuated.  The  small  mucous 
polypi  can  be  pinched  off  with  forceps  or  clipped  off  with 
the  scissors. 


CYSTIC   DEGENERATION    OF    THE    CERVIX 

Cystic  degeneration  of  the  cervix  is  one  of  the  results 
that  may  follow  an  infection  of  the  cervix.     During  the 


130 


DISEASES  OF  THE  CEEVIX 


inflammatory  process  the  superficial  portion  of  the  glands 
is  destroyed.  In  the  healing  process  after  the  infection 
has  subsided,  new  tissue  forms  over  the  remains  of  the 
partially  destroyed  glands.  The  epithelium  remaining  be- 
hind continues  to  secrete, 
but  as  there  is  no  outlet, 
a  small  cyst  is  formed.  In 
some  instances  these  cysts 
will  be  so  numerous  that 
a  section  through  them 
looks  like  a  section  through 
a  honeycomb.  Numerous 
small  cysts  of  this  character 
may  be  mistaken  on  macro- 
scopical  examination  for 
latent  adeno-carcinoma.  On 
microscopical  examination 
the  cystic  condition  is  easily 
recognized.  The  glands  are 
lined  by  a  single  layer  of 
columnar  epithelium  which, 
on  account  of  the  pressure  to  which  it  has  been  subjected,  is 
usually  lower  than  normal.  In  very  rare  instances  a  similar 
process  causes  the  formation  of  mucous  polypi  high  up  in 
the  cervical  canal. 


Fig.  64.  —  Cystic  Degeneration  of 
the  Cervix. 


STENOSIS    OF   THE    CERVIX 


Stenosis  of  the  cervix  is  a  narrowing  of  some  portion  of 
the  cervical  canal.  The  narrowest  points  are  usually  either 
at  the  external  or  internal  os.  The  condition  may  be  a 
congenital  one,  or  it  may  result  from  cicatrices  following 
injuries  received  during  labor  or  that  are  the  result  of 
operations  on  the  cervix. 


ATRESIA    OF    THE    CERVIX  131 

Symptoms.  —  Dysmenorrhea  is  the  most  marked  symp 
torn.  It  is  most  severe  the  first  day  of  the  period.  The 
pain  is  intermittent.  After  the  first  twenty-four  hours  it 
usually  decreases.  Sterility  is  also  very  common,  but  is 
probably  due  more  frequently  to  an  associated  endocer- 
vicitis  than  to  the  stenosis. 

Diagnosis.  —  When  the  stenosis  is  at  the  external  os  it 
can  be  recognized  by  digital  examination  and  by  inspection. 
When  the  stenosis  is  higher  in  the  cervical  canal  it  can 
be  recognized  by  the  uterine  sound.  In  the  congenital  cases 
the  uterus  is  usually  very  small.  In  the  acquired  cases  the 
stenosis  will  be  found  at  the  external  os. 

Treatment.  —  In  some  of  the  acquired  cases  it  may  be 
necessary  to  amputate  the  cervix  to  remove  the  cicatrix. 
In  all  other  cases  very  good  results  are  obtained  by  dilating 
and  packing  the  cervix  as  is  recommended  in  anteflexion 
of  the  uterus. 

ATRESIA   OF   THE    CERVIX 

Atresia  of  the  cervix  is  a  complete  closure  of  the  cervical 
canal.  It  may  be  congenital  or  acquired.  Acquired  atresia 
may  be  due  to  the  contraction  of  cicatrices  after  injury  to 
the  cervix  received  during  labor,  cauterization  of  the  cervix, 
amputation,  or  attempts  at  repair  of  lacerations  of  the 
cervix.  Adenocarcinoma  of  the  cervix  may  completely 
close  the  canal,  but  this  result  rarely  follows  other  cervical 
growths.  If  the  atresia  is  congenital  or  occurs  before  the 
menopause,  the  uterus  will  fill  up  with  blood  and  mucus. 
After  the  menopause  the  uterus  becomes  distended  with 
mucus.  In  either  case  the  contents  may  become  infected, 
resulting  in  a  pyometria. 

Diagnosis.  —  By  vaginal  examination  the  cervix  will  be 
found  to  be  closed.    This  closure  is  usually  at  the  external 


132  DISEASES    OF    THE    CEEVIX 

os  and  can  readily  be  felt  and  seen.  On  bimanual  examina- 
tion the  body  of  the  uterus  is  found  enlarged,  cystic,  and 
usually  tender  on  pressure. 

Treatment.  —  An  opening  is  made  into  the  cervix  either 
by  amputating  the  lower  part  of  the  cervix  or  by  making 
a  deep  antero-posterior  incision  and  a  transverse  incision. 
After  the  contents  of  the  uterus  are  evacuated,  the  cervical 
canal  must  be  kept  open  by  an  intrauterine  stem  or  by  a 
gauze  pack. 


HYPERTROPHY    OF    THE    CERVIX 

Hypertrophy  of  the  cervix  occurs  in  two  forms,  —  the 
general  enlargement  of  the  cervix  which  is  associated  with 
subinvolution  of  the  uterus,  and  hypertrophic  elonga- 
tion of  the  cervix  either  above  or  below  the  vaginal 
attachment. 

Elongation  of  the  Vaginal  Portion.  —  In  this  condition 
the  cervix  projects  low  into  the  vagina  and  sometimes  en- 
tirely through  the  vaginal  outlet.  It  is  very  commonly  mis- 
taken for  prolapse  of  the  uterus.  It  can  be  readily  recog- 
nized by  bimanual  examination.  The  long  narrow  cervix 
can  be  felt  in  the  vagina,  while  the  body  of  the  uterus  is 
found  in  its  normal  position.  This  form  of  cervical  hyper- 
trophy is  usually  congenital. 

Elongation  of  the  Supravaginal  Portion.  This  is  the 
form  that  is  sometimes  found  associated  with  prolapse  of 
the  uterus.  On  bimanual  examination  the  cervix  above 
the  vaginal  attachment  is  found  to  be  very  much  longer 
than  normal,  while  the  whole  uterus  is  displaced  down- 
ward. 

Treatment.  —  In  the  cases  associated  with  subinvolution 
and  in  the  cases  of  hypertrophic  elongation  of  the  vaginal 
portion  of  the  cervix,  an  amputation  may  be  done  as  de- 


HYPERTROPHY    OF    THE    CERVIX  133 

scribed  under  amputation  of  the  cervix  for  the  removal 
of  cicatricial  tissue  due  to  lacerations.  In  the  cases  where 
the  hypertrophy  is  associated  with  prolapse  of  the  uterus 
a  cervical  amputation  is  done  as  a  part  of  the  operation  for 
the  relief  of  the  prolapse. 


CHAPTEE   XI 

DISEASES    OF    THE    ENDOMETRIUM 

ENDOMETRITIS 

Endometritis  is  an  inflammation  of  the  mucous  membrane 
lining  the  body  of  the  uterus. 

Etiology.  —  The  direct  cause  of  endometritis  is  an  inva- 
sion of  the  endometrium  by  pathogenic  micro-organisms. 
The  micro-organisms  most  frequently  causing  it  are  the 
gonococcus,  streptococcus,  colon  bacillus,  and  bacillus  tuber- 
culosis, but  it  may  be  due  to  some  of  the  other  pus-produc- 
ing bacteria.  Anything  that  interferes  with  the  nutrition  of 
the  uterine  mucosa  may  act  as  an  indirect  cause  by  favor- 
ing the  possibilities  of  infection.  Among  these  indirect 
causes  are  all  the  systematic  diseases  that  impoverish  the 
blood,  uterine  displacements,  uterine  fibroids,  and  pelvic 
growths  that  interfere  with  the  return  flow  of  blood  from 
the  uterus. 

Pathology.  —  In  the  majority  of  cases  an  endometritis  is 
associated  with  salpingitis,  because  in  most  instances  any 
infection  that  passes  the  internal  os  continues  to  spread  by 
continuity  to  the  tubes.  Before  attempting  to  understand 
the  changes  taking  place  in  the  endometrium  that  are  due  to 
an  infection,  it  is  necessary  for  one  to  be  familiar  with  the 
changes  that  take  place  in  the  endometrium  associated  with 
the  menstrual  cycle.    These  are  described  on  page  92. 

The  changes  due  to  an  infection  include  the  changes  in 
the  superficial  epithelium  and  the  epithelium  lining  the 
glands,  the  contents  of  the  glands,  the  stroma  cells,  and  the 

134 


ENDOMETRITIS 


135 


small  round  cells.  One  of  the  first  changes  that  is  noted 
is  the  tremendous  increase  in  the  number  of  small  round 
cells.  These  can  be  seen  scattered  thickly  throughout  the 
stroma  in  the  infected  area.  They  penetrate  between  the 
cells   of   the   superficial    epithelium   and   escape   into   the 

d     b  e 


Fig.  65.  —  Endometritis.  (Photomicrograph.)  The  endometrium  during 
the  active  stages  of  an  infection;  a,  a  are  enlarged  stroma  cells;  b,  b,  modified 
epithelial  cells;  c,  round  cells  and  leucocytes  within  the  calibre  of  the  gland; 
d,  small  round  cell  between  the  epithelial  cells;  e,  small  round  cells  in  the  stroma. 

cavity  of  the  uterus.  They  pass  through  the  glandular 
epithelium  into  the  lumen  of  the  glands.  The  superficial 
epithelium  changes  its  shape,  becomes  rounded,  and  in  some 
areas  is  completely  destroyed.  The  same  process  takes 
place  in  the  epithelium  lining  the  glands.  The  destruction 
of  the  epithelium  lining  a  gland  or  any  portion  of  it  means 
the  permanent  destruction  of  that  portion  of  the  gland 
in  which  the  epithelium  is  destroyed.     These  changes  in 


136 


DISEASES    OF    THE    ENDOMETRIUM 


the  glandular  epithelium  are  much  more  marked  and  more 
frequent  in  the  superficial  than  in  the  deep  portion  of  the 
endometrium,  although  the  process  may  extend  the  whole 
length  of  the  glands  and  involve  the  entire  endometrium 
(Fig.  65).  The  secondary  result  from  this  effect  upon  the 
glandular  epithelium  is  that  when  the  outer  portions  of  the 


B 


Fig.  66.  —  Endometritis.  (Photomicrograph.)  One  of  the  later  stages  of  cell 
changes  due  to  infection  is  shown.  Round  cells  are  still  present  in  considerable 
numbers.  Most  of  the  stroma  cells  have  assumed  a  spindle  shape.  A,  A,  spindle 
cells;  B,  small  round  cells. 

glands  are  destroyed  the  deeper  portions  that  remain  be- 
come dilated.  In  exceptional  cases  practically  all  the  glands 
in  the  endometrium  are  completely  destroyed.  The  stroma 
cells  under  the  first  influence  of  the  infection  swell  up,  be- 
come more  rounded,  and  approach  in  type  the  decidual 
cells.  Later  they  have  a  tendency  to  become  spindle-shaped 
(Fig.  66),  and  if  the  process  continues,  they  become  fibro- 


ENDOMETRITIS 


137 


blasts.  In  the  active  stages  of  infection  many  of  the  glands 
are  filled  with  small  round  cells,  leucocytes,  broken-down 
epithelium,  and  mucus.  After  the  inflammatory  process 
has  passed  by,  it  leaves  permanent  changes  in  the  endo- 
metrium.   The  superficial  epithelium  is  apparently  always 


B 


B 


Fig.  67.  —  Endometritis.  (Photomicrograph.)  An  endometrium  that  has 
been  infected  is  shown.  The  superficial  part  of  the  endometrium  contains  glands 
that  are  narrow  and  very  irregular  in  outline.  The  deeper  part  of  the  endometrium 
shows  glands  that  are  very  much  dilated.  Under  higher  magnification  the  stroma 
is  shown  to  be  made  up  of  spindle  cells  and  fibroblasts.  A,  narrow  irregular 
glands;  B,  dilated  glands. 

restored ;  but  the  partially  and  completely  destroyed  glands 
are  never  restored.  The  stroma  cells  that  have  been  con- 
verted into  spindle  and  fibroblastic  cells  never  recover 
(Fig.  67). 

Symptoms.  —  Since  endometritis  is  so  commonly  associ- 
ated with  metritis  and  salpingitis,  the  symptoms  due  to  it 
are  blended  with  the  symptoms  due  to  the  associated  patho- 


138 


DISEASES    OF    THE    ENDOMETRIUM 


logical  lesions.  Menorrhagia  and  leucorrhea  are  the  two 
most  distinctive  symptoms.  The  uterine  discharge  is 
usually  white,  thin,  and  milky  in  appearance,  but  it  is  some- 
times distinctly  purulent.  It  is  usually  increased  in  quan- 
tity just  before  and  just  after  the  menses.    There  may  be 


Fig.  68.  —  Tuberculous  Endometritis.  (Photomicrograph.)  The  posi- 
tion of  three  closely  grouped  giant  cells  is  shown  surrounded  by  a  caseous 
area.  Just  beyond  the  caseous  area  is  an  intense  round-cell  infiltration. 
A,  giant  cell;  B,  caseous  area;  C,  area  of  round-cell  infiltration. 

some  sense  of  weight  and  dragging  in  the  pelvis  and  some 
backache. 

Diagnosis.  —  On  bimanual  examination  in  the  absence  of 
salpingitis,  the  uterus  is  found  to  be  freely  movable,  slightly 
enlarged,  and  somewhat  tender  on  pressure.  The  only 
method  of  making  a  positive  diagnosis  is  by  microscopical 
examination  of  scrapings. 

Treatment.  —  In  recent] v  infected  cases  the  treatment 


HYPERTKOPHIC    ENDOMETRIUM  139 

should  be  limited  to  the  use  of  glycerin  tampons  or  other 
means  for  the  promotion  of  drainage.  All  intrauterine 
applications  are  positively  contraindicated.  In  long  stand- 
ing cases  the  uterus  may  be  dilated  and  thoroughly  scraped 
out  with  a  sharp  curette. 


TUBERCULOUS    ENDOMETRITIS 

Tuberculous  infection  of  the  endometrium  is  usually  asso- 
ciated with  tuberculous  infection  of  the  tubes. 

Symptoms.  —  The  symptoms  of  tuberculous  endometritis 
are  practically  the  same  as  those  of  other  forms  of  in- 
fection of  the  endometrium.  There  is  a  leucorrheal  dis- 
charge and  usually  a  menorrhagia,  though  in  cases  of  ad- 
vanced general  tuberculosis  there  may  be  amenorrhea. 

Diagnosis.  —  The  diagnosis  can  be  made  by  the  examina- 
tion of  the  scrapings.  Definite  giant  cells  can  usually  be 
distinguished.  There  are  numerous  small  caseous  areas 
surrounded  by  marked  small  round-cell  infiltration  (Fig. 
68).  These  caseous  areas  without  the  giant  cells  are  quite 
sufficient  for  a  diagnosis  because  they  do  not  occur  in  any 
other  form  of  endometritis. 

Treatment.  —  Cases  have  been  cured  by  thorough  curette- 
ment,  but  the  conservative  measure  is  to  remove  the  uterus 
and  tubes. 


HYPERTROPHIC    ENDOMETRIUM 

This  condition  is  met  with  in  patients  of  all  ages,  but 
is  most  frequently  seen  about  the  time  of  the  menopause. 
It  has  been  confused  with  endometritis.  In  this  condition 
the  mucosa  remains  permanently  in  a  state  very  similar  to 
the  pre-menstrual  endometrium,  except  that  in  the  hyper- 
trophic endometrium  there  is  usually  an  actual  increase 


140  DISEASES    OF    THE    ENDOMETEIUM 

in  the  number  of  glands.  The  glands  are  increased  in  size 
and  filled  with  mucus.  The  epithelium  lining  the  glands 
retains  its  normal  relation  to  the  interstitial  tissue  and  to 
itself ;  that  is,  a  single  layer  of  epithelium  lines  the  glands 
and  there  is  no  piling  up  of  epithelium  in  the  gland  and 
no  tendency  for  it  to  break  through  into  the  stroma. 

Symptoms.  —  The  only  symptom  of  importance  is  the 
hemorrhage,  which  may  be  only  a  menorrhagia  or  may  be 
a  persistent  metrorrhagia.  In  either  case  the  flow  may 
be  very  profuse,  but  is  more  frequently  a  persistent  rather 
than  a  free  flow. 

Diagnosis.  —  The  diagnosis  is  made  by  a  microscopical 
examination  of  the  scrapings. 

Treatment.  —  Thorough  curettement  is  the  most  satis- 
factory treatment.  In  many  cases  the  curettement  must  be 
repeated.  In  rare  instances  the  hemorrhage  can  be  con- 
trolled permanently  only  by  removing  the  uterus. 

ADENOMA 

Adenoma  occurring  in  the  cavity  of  the  uterus  is  a  con- 
dition very  similar  to  that  of  hypertrophy  of  the  endo- 
metrium, except  that  in  the  adenoma  there  is  such  an  in- 
crease in  the  glands  and  in  the  inter-glandular  substance 
that  a  tumor  is  formed. 

Pathology.  —  On  microscopical  examination  an  adenoma 
presents  practically  the  same  picture  as  that  of  hypertrophy 
of  the  endometrium.  It  is  most  frequently  confused  with 
adeno-carcinoma.  To  distinguish  these  two  it  is  only 
necessary  to  closely  observe  the  epithelium  lining  the 
glands.  In  the  adenoma,  the  epithelium  lining  the  glands 
presents  the  same  appearance  as  in  a  normal  uterine  gland. 
There  is  no  piling  up  of  the  epithelium  in  the  glands  and 
no  tendency  of  this  epithelium  to  break  through  into  the 


ADENOMA 


141 


stroma.  All  of  the  glands  present  the  same  general  ap- 
pearance (Fig.  69).  In  adeno-carcinoma  the  epithelium 
lining  the  different  glands  in  the  same  section  show  great 
variations.  In  a  few  the  epithelium  may  appear  to  be 
normal,  but  in  most  of  the  glands  the  epithelium  will  be 
seen  piling  up  on  itself,  and  filling  up  the  gland.    In  other 


Fig.  69.  —  Adenoma.  (Photomicrograph.)  It  is  noted  that  the  numerous 
gland  spaces  are  lined  by  a  uniform  thickness  of  epithelium. 

places  it  may  be  seen  breaking  from  the  gland  space  out 
into  the  stroma. 

Symptoms.  —  The  most  important  symptom  produced  by 
an  adenoma  is  uterine  hemorrhage. 

Diagnosis.  —  Diagnosis  is  made  by  microscopical  exami- 
nation of  the  growth. 

Treatment.  —  The  growth  can  usually  be  completely  re- 
moved by  a  sharp  curette. 


CHAPTER   XII 


CARCINOMA    OF    THE    UTERUS 


Histology.  —  The  mucous  membrane  of  the  vaginal  por- 
tion of  the  cervix  is  covered  with  stratified  squamous  epi- 
thelium.   The  mucous  membrane  of  the  cervical  canal  and 

the  glands  in  it  are  lined 


by  a  single  layer  of  high 
columnar  epithelium.  The 
surface  and  the  glands  of 
the  endometrium  of  the 
body  are  lined  with  a  single 
layer  of  low  columnar  epi- 
thelium. From  these  three 
varieties  of  epithelium 
there  develop  three  varie- 
ties of  carcinoma.  The 
most  common  form  of  carci- 
noma of  the  uterus  develops 
from  the  squamous  epithe- 
lium of  the  cervix  and 
usually  begins  at  the  point 
of  junction  of  the  squamous  and  columnar  epithelium. 
It  is  called  squamous  cell  carcinoma  or  epithelioma.  From 
the  high  columnar  epithelium  of  the  cervical  canal  is 
developed  the  adeno-carcinoma  of  the  cervix.  From  the 
low  columnar  epithelium  of  the  endometrium  develops  the 
adeno-carcinoma  of  the  body  of  the  uterus. 

142 


Fig.  70.  —  Epithelioma  op  the  Cer- 
vix.   A  cauliflower  growth. 


PATHOLOGY 


14.' 


Pathology.  —  Epithelioma,  or  squamous  cell  carcinoma, 
of  the  cervix  is  met  with  in  various  forms.  These  varia- 
tions in  appearance  can  be  roughly  classified  into  three 
groups.  In  an  early  stage  the  cervix  presents  small  hard 
nodules  with  an  unbroken  surface,  but  which  bleeds  rather 
easily  if  manipulated.  In  other  cases  a  cauliflower-like 
growth  is  found  projecting 
from  the  vaginal  portion  of 
the  cervix  (Fig.  70).  These 
projections  are  very  fragile, 
and  when  broken  off  bleed 
profusely.  They  may  be  con- 
sidered the  second  stage  in  the 
development  of  carcinoma  of 
the  cervix,  but  in  many  cases 
this  formation  never  takes 
place.  The  third  group  are 
those  observed  after  a  certain 
amount  of  breaking  down  or 
ulceration     has     taken     place 

(Fig.      71).        This      ulceration         Fig.  71.  — Epithelioma  op  the 
p   11  ,.         . ,  p.  .,        Cervix.     The    tumor    has    broken 

may  follow  directly  after  the   down  leaving  a  cavity> 
hard  nodular  stage  or  it  may 

follow  the  breaking  down  of  the  cauliflower  growth. 
There  is  present  a  deep  excavation  surrounded  by  hard 
indurated  nodular  borders  which  bleed  easily  on  manipu- 
lation. If  a  section  of  an  early  carcinoma  of  the  cervix 
is  examined  with  a  microscope,  the  normal  epithelium 
on  the  outside  of  the  cervix  can  be  traced  directly  to  the 
point  where  it  begins  to  dip  down  into  the  tissues  and  the 
cells  change  their  character.  It  will  be  noted  that  the  cancer 
cells  stain  very  much  more  deeply  than  the  normal  vaginal 
epithelial  cells,  that  they  are  irregular  in  size,  and  that  in 
the  connective  tissue  just  beneath  the  cancerous  growth 


1U 


CARCINOMA    OF    THE    UTERUS 


there  is  a  marked  small  round-cell  infiltration.  The  cancer 
cells  form  columns  that  grow  directly  down  into  the  sub- 
epithelial'tissues.  These  columns  when  cut  transversely 
show  what  are  called  the  cell  nests.  They  are  more  or  less 
rounded  masses  of  epithelial  cells  surrounded  by  the  stroma 
of  the  cervix  which  is  infiltrated  with  small  round  cells. 


Fig.  72.  —  Epithelioma  of  the  Cervix.  (Photomicrograph.)  A,  masses  of 
epithelial  cells  pushing  into  the  cervical  tissues;  B,  tissue  deeply  infiltrated  with 
small  round  cells;  C,  cervical  muscularis. 

When  one  of  the  cauliflower  projections  is  examined  it 
is  found  to  consist  of  a  stem  of  newly  formed  connective 
tissue  covered  on  the  outside  by  many  layers  of  irregular 
epithelial  cells.  In  other  words,  the  cauliflower  projections 
are  made  up  of  an  overgrowth  of  atypical  epithelial  cells 
combined  with  an  overgrowth  of  the  subjacent  stroma  cells. 
The  stroma  is  deeply  infiltrated  with  polynuclear  leucocytes 
and  small  round  cells. 


PATHOLOGY 


145 


When  a  section  from  the  border  or  more  recently  de- 
veloped portion  of  an  epithelioma  that  has  undergone  ulcer- 
ation is  examined,  the  same  cell  changes  are  found  that  are 
seen  in  a  beginning  carcinoma.  In  the  older  portions  of 
the  growth  there  is  much  infiltration  of  polynuclear  leuco- 


Fig.  73.  —  Epithelioma  of  the  Cervix.  (Photomicrograph.)  This  picture 
is  made  from  the  same  slide  that  Fig.  72  is  from.  The  higher  magnification  shows 
the  character  of  the  epithelial  cells.  They  are  irregular  in  size  and  do  not  stain 
uniformly. 


cytes  into  the  cell  nests.  This  process  of  infiltration  goes 
on  until  there  is  liquefaction  and  breaking  down  of  the 
epithelial  masses  leaving  only  the  remnants  of  connective 
tissue  between  them.  This  connective  tissue  ultimately 
necroses,  leaving  a  deep  cavity.  The  cancerous  process 
starts  near  the  external  os  and  rarely  extends  upward  into 
the  uterus  farther  than  the  internal  os.    It  has  a  tendencv 


146 


CARCINOMA    OF    THE    UTERUS 


to  extend  early  into  the  broad  ligaments  by  continuity  of 
tissue,  and  to  metastasize  later  by  way  of  the  lymphatics. 

Three  distinct  varieties  of  squamous  cell  carcinoma  of 
the  cervix  are  recognized.  The  first  is  made  up  of  cells 
from  all  the  layers  of  the  epithelium.     It  can  usually  be 


Fig.  74.  —  Epithelioma  of  the  Cervix.  (Photomicrograph.)  Basal  cell 
epithelioma.  A,  are  isolated  masses  of  epithelial  cells.  Under  a  higher  magnifica- 
tion these  cells  are  shown  to  be  uniform  in  size  and  staining  qualities. 

recognized  by  the  irregularity  in  the  size  of  the  cells  and 
by  the  irregular  distribution  of  the  chromatin  (Figs.  72 
and  73).  This  type  of  epithelioma  is  the  one  usually  found 
in  the  younger  women  and  extends  very  rapidly.  The 
second  variety  apparently  grows  only  from  the  basal  layer 
of  epithelium  and  is  known  as  basal  cell  carcinoma.  The 
cell  nests  have  very  definitely  rounded  outlines  (Fig.  74). 
It  can  be  recognized  by  the  uniformity  of  its  cells  both  in 
size  and  in  distribution  of  chromatin  and  the  usual  absence 


PATHOLOGY 


14' 


of  pearls  and  prickle  cells.  It  metastasizes  less  rapidly  and 
the  probability  of  its  recurrence  after  removal  is  less  than 
that  of  the  first  variety.  In  the  third  or  schirrus  form  of 
epithelioma  there  is  apparently  a  very  slow  invasion  by 
the  epithelial  cells.  The  cells  stain  poorly.  There  is  an 
increase  in  the  connective  tissue  which  apparently  affords 


Fig.  75.  —  Epithelioma  of  the  Cervix.  (Photomicrograph.)  Schirrus  car- 
cinoma. The  dark  areas  indicate  the  distribution  of  the  invading  epithelium. 
The  light  areas  indicate  the  distribution  of  the  overgrowth  connective  tissue. 


great  resistance  to  the  invading'  epithelial  cells  (Fig.  75). 
The  result  is  that  the  malignant  growth  makes  very  slow 
progress  and  may  extend  over  a  long  period  of  years  before 
there  is  any  great  destruction  of  the  tissue. 

Adeno-carcixoma  of  the  cervix  often  begins  well  up  in 
the  cervical  canal  and  frequently  progresses  until  the  cer- 
vix is  almost  entirely  destroyed  before  it  breaks  through 


148 


CARCINOMA    OF    THE    UTERUS 


into  the  vagina.  When  the  disease  begins  in  the  canal  near 
the  external  os  the  lips  are  thickened  and  infiltrated.  In 
some  cases  there  is  almost  a  complete  destruction  of  the 
cervix,  only  a  hard  nodular  mass  remaining  which  has  a 
central  opening  in  it  allowing  the  outflow  of  a  foul  dis- 


,_    ,_ 

Mm 

Tfl^H     mm  ■ 

:^W 

40*-.  ^^4(»iS9^r^lF 

^Vi| 

Fig.  76.  —  Adeno-carcinoma  op  the  Cervix.  (Photomicrograph.)  Numer- 
ous atypical  glands  filled  with  many  layers  of  irregular  epithelium  are  shown. 
Very  little  cervical  tissue  has  been  left. 


charge.  The  growth  sometimes  entirely  closes  the  cervical 
canal  and  the  uterus  becomes  distended  with  pus.  It  tends 
to  break  through  the  rectal  and  bladder  walls  causing 
fistulae.  On  microscopic  examination  a  very  great  increase 
in  the  number  of  atypical  glands  is  seen.  These  glands 
project  into  the  stroma  of  the  cervix.  The  epithelium 
lining  the  glands  proliferates  rapidly,  having  a  tendency 
to  pile  upon  itself  and  ultimately  to  fill  up  the  gland  spaces 


PATHOLOGY  149 

(Fig.  76).     In  the  later  stages  of  the  process  it  breaks 
through  the  basement  membrane. 

The  epithelial  cells  of  the  adeno-carcinoma  differ  greatly 
from  those  of  the  normal  cervical  epithelium.  The  nuclei 
may  be  of  almost  any  shape  or  form  and  stain  very  irregu- 
larly.    The  newly  formed  cells  usually  stain  deeply.     The 


Fig.  77.  —  Adeno-carcinoma  of  the  Body  of  the  Uterus.  It  is  noted  that 
only  the  cavity  of  the  uterus  above  the  internal  os  is  involved.  A  shaggy  growth 
projects  into  the  cavity  of  the  uterus.  Fig.  78  was  made  from  a  section  of  this 
uterus. 

stroma  of  the  growth  is  the  undestroyed  portion  of  the 
cervical  tissue  and  is  usually  infiltrated  by  small  round  cells. 
Adeno-carcinoma  of  the  cervix  has  less  tendency  to  break 
down  than  squamous  cell  carcinoma.  It  causes  very  little 
hemorrhage  and  consequently  attention  is  rarely  called 
to  it  until  it  is  far  advanced. 

Adeno-carcinoma  of  the  body  of  the  uterus  usually  be- 
gins at  one  point  in  the  endometrium.    In  exceptional  cases 


150 


CAECINOMA    OF    THE    UTERUS 


the  whole  endometrium  is  apparently  involved  from  the 
beginning.  The  body  of  the  uterus  may  be  somewhat  en- 
larged. The  growth  starts  usually  by  producing  finger- 
like  projections  on  the  endometrium.  On  microscopic  ex- 
amination it  is  observed  that  the  number  of  glands  is  very 
much  increased,  the  epithelium  lining  the  glands  is  modified 


Fig.  78.  —  Adenocarcinoma  of  the  Body  of  the  Uterus.  (Photomicro- 
graph . )  M  any  atypical  glands  filled  with  much  irregular  epithelium  are  seen  grow- 
ing into  the  muscularis. 

in  character,  and  the  number  of  epithelial  cells  tremendously 
increased.  This  increase  in  the  number  of  epithelial  cells 
causes  them  to  pile  up  within  the  gland.  The  proliferation 
of  the  epithelial  cells  is  always  irregular,  so  that  there  are 
scarcely  two  glands  that  present  the  same  general  appear- 
ance (Fig.  78).  In  the  later  stages  the  proliferation  of 
cells  may  increase  to  such  an  extent  that  the  appearance 
of  the  gland  structure  is  almost  completely  lost. 


COURSE  151 

The  two  conditions  most  frequently  confused  with  adeno- 
carcinoma of  the  body  of  the  uterus  are  a  benign  adenoma 
growing  from  the  endometrium  and  the  changes  in  the 
glands  that  are  found  in  early  pregnancy.  In  an  early 
pregnancy  there  is  an  increase  in  the  number  of  epithelial 
cells  within  the  gland,  but  there  is  a  decrease  in  the  amount 
of  chromatin  in  these  cells.  There  is  a  marked  uniformity 
in  the  general  appearance  of  all  the  glands  shown.  There 
is  no  increase  in  the  number  of  glands.  There  are  present 
the  decidual  cells  in  the  stroma. 

Etiology.  —  No  definite  cause  of  carcinoma  is  known.  It 
occurs  most  commonly  after  the  age  of  thirty-live,  although 
no  age  is  absolutely  exempt.  The  majority  of  cases  are 
seen  between  the  ages  of  forty  and  fifty-five.  Lacerations 
of  the  cervix  apparently  favor  the  development  of  carci- 
noma. It  has  been  observed  that  nearly  all  women  who 
have  epithelioma  of  the  cervix  have  borne  children  or 
have  had  the  cervix  forcibly  dilated.  Adeno-carcinoma  of 
the  body  of  the  uterus  has  been  noted  with  greater  fre- 
quency in  connection  with  submucous  fibroids  than  under 
any  other  condition.  The  presumption  is  that  the  pres- 
sure exerted  by  the  fibroid  upon  the  mucous  membrane 
has  a  direct  relation  to  the  development  of  the  carcinoma. 
It  is  very  probable  that  carcinoma  is  due  to  a  specific  in- 
fection and  that  laceration  of  the  cervix  and  pressure 
from  fibroids  serve  only  to  increase  the  opportunities  for 
infection. 

Course.  —  In  all  forms,  carcinoma  of  the  uterus  is  in  the 
beginning  a  local  disease  which,  if  removed  completely,  will 
not  return.  Epitheliomata  extend  early  by  direct  continuity 
of  tissue  into  the  broad  ligaments,  and  later  to  the  other 
structures  in  the  pelvis,  either  by  direct  continuity  or  by 
way  of  the  lymphatics.  The  patient  loses  strength  rapidly 
from  the  continuous  loss  of  blood  and  from  the  toxemia. 


152  CARCINOMA    OF    THE    UTEEUS 

The  toxemia  is  due  to  the  absorption  of  ptomaines  formed 
in  the  process  of  suppuration  and  necrosis. 

The  form  of  epithelioma  which  develops  from  all  the 
layers  of  the  squamous  epithelium  destroys  tissue  most 
rapidly  and  metastasizes  earliest.  The  prognosis  in  this 
form  of  epithelioma,  however  early  it  is  seen,  is  always  bad. 
The  basal  cell  epithelioma  develops  more  slowly  and  the 
schirrus  is  the  least  malignant  of  the  epitheliomata. 

Adeno-carcinoma  of  the  cervix  produces  so  little  dis- 
turbance that  it  is  usually  not  discovered  until  the  cervix 
is  practically  destroyed  and  metastasis  to  the  broad  liga- 
ments has  already  taken  place.  It  is  considered  the  most 
malignant  of  all  the  carcinomata  of  the  uterus. 

Adeno-carcinoma  of  the  body  of  the  uterus  does  not 
metastasize  early  but  does  promptly  cause  hemorrhage. 
Consequently  where  the  proper  examination  is  made  it 
can  often  be  removed  before  it  has  progressed  very  far. 
A  much  larger  percentage  of  patients  suffering  from  adeno- 
carcinoma of  the  body  are  permanently  cured  than  those 
who  have  any  other  form  of  carcinoma  of  the  uterus.  If 
neglected  it  ultimately  extends  through  the  uterine  wall  and 
continues  to  develop  in  any  of  the  viscera  with  which  it 
comes  in  contact.  No  statistics  giving  the  permanent  re- 
coveries after  operation  for  carcinomata  of  the  uterus 
are  of  any  value  unless  the  definite  varieties  removed  are 
stated. 

Symptoms.  —  The  most  important  symptom  of  carcinoma 
of  the  uterus  is  hemorrhage.  In  women  during  the  men- 
strual age  this  hemorrhage  usually  shows  itself  at  first  as 
an  increased  menstrual  flow  which  gradually  increases  until 
it  becomes  more  or  less  continuous.  Occasionally  very  pro- 
fuse hemorrhages  occur.  Hemorrhage  after  the  meno- 
pause is  especially  significant  of  carcinoma.  This  is  the 
period  of  life  in  which  carcinoma  comes  most  frequently. 


DIAGNOSIS  153 

Carcinoma  is  one  of  the  few  pathological  changes  that  pro- 
duces hemorrhage  after  the  menopause.  All  cases  that 
bleed  excessively  about  the  time  of  the  menopause  and  all 
cases  that  bleed  even  slightly  after  the  establishment  of 
the  menopause  should  be  immediately  investigated.  The 
squamous  cell  carcinoma  does  not  cause  hemorrhage  until 
after  it  begins  to  break  down.  The  adeno-carcinoma  of 
the  cervix  may  never  cause  any  hemorrhage.  Adeno- 
carcinoma of  the  body  of  the  uterus  occurring  before  the 
establishment  of  the  menopause  causes  at  once  an  increased 
menstrual  flow.  "Where  the  growth  begins  after  the  estab- 
lishment of  the  menopause  the  hemorrhage  is  usually,  in 
the  beginning,  a  slight  continuous  dribble  which  has  a  ten- 
dency to  increase  in  volume. 

Even  before  hemorrhage  occurs  there  is  frequently  a 
thin  watery  discharge.  Unfortunately  leucorrhea  is  such 
a  common  condition  that  usually  very  little  attention  is 
paid  to  the  discharge  due  to  a  malignant  growth.  As  the 
disease  progresses  this  watery  discharge  becomes  discol- 
ored with  blood.  During  the  process  of  necrosis  there  is 
a  profuse  extremely  fetid  discharge.  It  has  a  tendency 
to  irritate  the  mucous  membranes  over  which  it  passes. 
The  odor  is  so  characteristic  that  it  is  a  very  material 
aid  to  diagnosis. 

Pain  due  to  carcinoma  does  not  begin  until  after  the 
structures  outside  the  uterus  are  involved.  There  is  noth- 
ing characteristic  about  it  and  it  varies  according  to  the 
organs  involved  in  the  metastases.  It  usually  comes  on  too 
late  to  be  of  any  practical  use  in  making  a  diagnosis. 

The  cachexia  caused  by  carcinoma  does  not  appear  until 
the  disease  is  well  advanced  and  is  due  to  the  absorption 
of  toxins  and  to  the  loss  of  blood. 

Diagnosis.  —  It  is  of  the  greatest  importance  to  make  a 
diagnosis  of  carcinoma  as  early  as  possible.    The  diagnosis 


154  CARCINOMA    OF    THE    UTEEUS 

of  epithelioma  of  the  cervix  can  usually  be  made  by  ordi- 
nary vaginal  examination.  The  cervix  may  be  found  to 
present  irregular  nodules,  a  cauliflower  growth,  or  a  crater- 
like ulcer  with  hard,  elevated  edges.  Some  hemorrhage  is 
almost  invariably  produced  by  the  examination.  The  con- 
dition of  the  cervix  taken  in  connection  with  the  age  of 
the  patient  and  the  history  of  hemorrhage  are  very  sig- 
nificant of  carcinoma.  A  portion  of  the  growth  for  micro- 
scopical examination  can  be  obtained  either  by  curettement 
or  by  clipping  a  wedge-shaped  portion  from  the  border 
of  the  growth.  The  microscopical  findings  are  described 
in  the  paragraph  on  pathology. 

Adeno-carcinoma  of  the  cervix  as  a  rule  causes  no  en- 
largement of  the  cervix  and  no  hemorrhage  or  other  dis- 
charge until  it  has  extended  very  widely  and  begins  to 
break  down.  An  early  diagnosis  of  adeno-carcinoma  of  the 
cervix  is  usually  only  made  in  the  course  of  routine  micro- 
scopical examination  of  uterine  scrapings.  In  adeno- 
carcinoma of  the  body  of  the  uterus  attention  is  usually 
directed  to  the  condition  by  the  hemorrhage.  On  bimanual 
examination  it  can  usually  be  recognized  that  the  body  is 
slightly  enlarged.  The  diagnosis  must  be  made  from  a 
specimen  secured  by  curettement.  The  microscopical  find- 
ings are  described  in  the  paragraph  on  pathology. 

Treatment.  —  The  ideal  treatment  for  carcinoma  of  the 
uterus  is  the  extirpation  of  all  tissues  involved  in  the 
growth.  Unfortunately  in  many  instances  the  carcinoma 
has  extended  into  tissues  so  far  beyond  the  uterus  before 
it  is  discovered  that  it  is  impossible  to  remove  the  whole 
of  it.  In  such  cases  it  is  folly  to  attempt  a  radical  operation, 
and  the  attending  physician  should  restrict  the  treatment 
to  palliative  measures  for  the  relief  of  symptoms  as  they 
arise.  There  are  no  hard  and  fast  lines  by  which  these 
cases  may  be  separated  into  the  two  groups  —  one  in  which 


TREATMENT  155 

complete  removal  should  be  attempted  and  the  one  in  which 
only  palliative  measures  should  be  used.  In  a  general  way 
it  can  be  stated  that  palliative  treatment  should  be  used  in 
those  cases  in  which,  by  ordinary  methods  of  examination, 
it  can  be  recognized  that  the  carcinoma  has  extended  be- 
yond the  uterus,  and  especially  those  in  which  the  broad 
ligaments  are  involved  to  such  an  extent  that  the  uterus  is 
fixed  in  a  definite  position;  and  that  in  all  cases  where 
the  uterus  is  movable  and  where  there  is  no  marked  infil- 
tration of  the  tissues  outside  of  the  uterus,  extirpation 
of  the  growth  should  be  undertaken. 

Palliative  Tkeatment.  —  By  palliative  treatment  we 
mean  treatment  that  is  administered  for  the  relief  of  symp- 
toms as  they  arise.  These  symptoms  are  hemorrhage,  pain, 
and  odor  from  the  discharge. 

For  the  relief  of  hemorrhage  the  most  efficient  measure 
is  the  use  of  the  curette  either  with  or  without  the  cautery. 
A  sharp  curette  that  is  as  wide  as  can  be  introduced  into 
the  cervical  canal  should  be  used  and  each  stroke  of  the 
curette  should  be  carried  down  as  nearly  as  possible  to  the 
healthy  tissue.  When  the  curettage  is  done  in  this  way 
there  is  less  loss  of  blood  than  when  the  same  area  is  scraped 
over  several  times.  After  the  entire  exposed  area  has  been 
curetted,  the  raw  surface  should  be  seared  over  with  a 
low  temperature  cautery.  This  stops  the  oozing  and  de- 
stroys a  little  more  of  the  malignant  growth  than  can  be 
removed  with  a  curette.  If  the  bleeding  is  not  entirely 
controlled  a  temporary  gauze  pack  should  be  put  in. 

For  the  relief  of  pain  morphia  should  be  administered  in 
sufficient  quantities  to  make  the  patient  comfortable  with- 
out any  reference  to  the  amount  necessary. 

To  control  the  odor  of  the  discharge  vaginal  douches  of 
a  weak  solution  of  permanganate  of  potassium,  boracic  acid, 
or  normal  salt  solution  may  be  used.    These  may  be  used 


156  CARCINOMA    OF    THE    UTERUS 

alternately.  The  solution  of  permanganate  of  potassium  is 
the  most  efficient,  but  it  is  not  advisable  to  use  it  exclusively. 

Radical  Treatment.  —  The  operations  for  the  extirpation 
of  carcinoma  of  the  uterus  may  be  divided  into  three  groups : 
they  are  high  amputation  of  the  cervix,  vaginal  hysterec- 
tomy, and  abdominal  hysterectomy. 

High  Amputation  of  the  Cervix.  —  Even  in  the  most  ad- 
vanced cases  epithelioma  of  the  cervix  rarely  extends  into 
the  uterus  beyond  the  internal  os.  On  account  of  this  fact 
a  high  amputation  of  the  cervix  with  the  removal  of  a  wide 
section  of  the  lower  half  of  the  broad  ligaments  offers 
as  great  a  possibility  for  the  complete  removal  of  the 
disease  as  does  a  hysterectomy. 

The  operation  is  done  by  exposing  the  cervix  by  means 
of  a  vaginal  speculum,  making  a  circular  incision  around 
it,  dissecting  back  a  cuff  of  mucous  membrane,  and  laying 
bare  the  cervix  nearly  or  quite  to  the  internal  os.  The 
lower  segments  of  the  broad  ligaments  of  both  sides  are 
clamped  as  far  from  the  cervix  as  possible.  The  broad 
ligaments  are  cut  through  close  to  the  clamps  and  the  cervix 
amputated  near  the  internal  os.  The  stumps  of  the  broad 
ligaments  are  cauterized  and  the  clamps  are  left  in  position. 
A  ligature  is  put  into  each  side  of  the  stump  of  the  cervix 
to  control  the  small  blood-vessels,  and  is  made  to  include 
the  ascending  portion  of  the  uterine  artery.  The  edge  of 
the  median  part  of  the  wound  in  the  mucous  membrane 
of  the  anterior  vaginal  wall  is  drawn  down  and  stitched  to 
the  endometrium  on  the  anterior  side  of  the  cervical  canal 
with  two  or  three  sutures.  The  same  procedure  is  carried 
out  posteriorly.  By  this  means  the  stump  of  the  cervix 
is  almost  covered  with  mucous  membrane  and  the  cervical 
canal  is  preserved.  One  or  two  stitches  in  the  vaginal 
mucous  membrane  on  either  side  of  the  cervical  canal  brings 
together  the  mucous  membrane  over  the  remainder  of  the 


TWKATMENT 


15' 


stump  of  the  cervix.     The  clamps  on  the  broad  ligaments 
are  allowed  to  remain  in  position  forty-eight  hours. 

Vaginal  Hysterectomy.  —  Before  proceeding  with  the 
operation  of  vaginal  hysterectomy,  especially  for  the  re- 
moval of  epitheliomata,  the  involved  area  should  be  curetted 
and  cauterized  or  amputated.    This  preliminary  work  may 


Fig.  79.  —  Vaginal  Hysterec- 
tomy. First  step.  A  circular  inci- 
sion has  been  made  around  the  cervix 
and  the  mucous  membrane  dissected 
up  as  is  shown  in  Figs.  57  and  58. 
The  peritoneum  between  the  uterus 
and  the  bladder  has  been  opened. 


Fig.  80.  —  Vaginal 
Hysterectomy.  Second 
step.  An  opening  has  been 
made  into  Douglas'  cul- 
de-sac. 


be  done  immediately  before  the  operation,  or  some  operators 
prefer  to  do  it  several  days  in  advance  of  the  operation. 
The  object  is  to  remove  the  infected  areas  and  decrease 
the  probability  of  infection  of  the  peritoneum  and  denuded 
tissues  during  the  operation.  The  hysterectomy  is  started 
by  making  a  circular  incision  through  the  vaginal  wall 
around  the  cervix  (Fig.  57).     This  incision  should  be  car- 


158 


CAECINOMA    OF    THE    UTEEUS 


ried  as  far  from  the  involved  portion  of  the  mucous  mem- 
brane as  possible.  By  blunt  dissection  a  cuff  of  the  vaginal 
wall  is  separated  from  the  uterus  on  all  sides  (Fig.  58). 
Behind,  the  dissection  is  carried  back  to  the  peritoneum. 
In  front,  the  working  space  can  be  much  increased  by  split- 
ting the  anterior  vaginal  wall  in  the  median  line.     The 


Fig.  81. — Vaginal  Hysterec- 
tomy. Third  step.  The  clamp  to  the 
left  of  the  uterus  is  on  the  lower  seg- 
ment of  the  left  broad  ligament.  The 
dotted  line  indicates  the  line  of  incision 
to  be  made  through  the  lower  part  of 
the  broad  ligament. 


Fig.  82.  —  Vaginal  Hysterec- 
tomy. Fourth  step.  The  fundus  of 
the  uterus  has  been  turned  forward  by 
the  method  shown  in  Fig.  28.  The 
clamp  is  on  the  upper  segment  of  the 
broad  ligament. 


bladder  is  separated  from  the  uterus  and  pushed  as  far 
forward  as  possible.  The  farther  it  is  separated  from  the 
uterus  the  less  danger  there  is  of  injuring  either  it  or  the 
ureters  during  the  operation.  The  peritoneum  is  opened 
by  a  long  transverse  incision  both  in  front  of  and  behind 
the  uterus  (Figs.  79  and  80).    The  lower  segments  of  the 


TREATMENT  159 

broad  ligaments  are  clamped  as  far  from  the  uterus  as 
possible  and  cut  free  (Fig.  81).  The  fundus  of  the  uterus 
is  then  turned  downwards  through  the  wound  in  the  an- 
terior vaginal  wall  and  brought  to  the  outside  (Fig.  28). 
The  upper  portions  of  the  broad  ligaments  are  clamped 
(Fig.  82),  and  incisions  are  carried  down  between  the  clamps 
and  the  uterus  to  meet  the  incisions  made  through  the  lower 
segments  of  the  broad  ligaments.  The  uterus  is  then  re- 
moved. The  stumps  of  the  broad  ligaments  are  cauterized 
down  to  the  clamps,  and  the  clamps  sufficiently  heated  with 
the  cautery  to  destroy  the  vitality  of  the  tissues  grasped. 
A  large  loose  gauze  pack  is  pushed  up  into  the  pelvis  be- 
tween the  clamps  and  a  piece  of  gauze  is  wrapped  around 
the  clamp  handles.  After  forty-eight  hours  the  clamps  are 
removed  and  in  another  twenty-four  hours  part  of  the  gauze 
packing  is  removed.  After  that  a  portion  of  the  pack  is 
removed  every  day.  The  last  part  is  usually  removed  the 
seventh  day  after  the  operation. 

Abdominal  Hysterectomy.  —  The  advocates  of  abdominal 
hysterectomy  for  carcinoma  claim  that  a  wider  area  of  the 
broad  ligaments  can  be  removed  by  that  route  than  by 
way  of  the  vagina,  and  that  through  the  abdominal  wound 
the  lymphatic  glands  may  also  be  removed.  It  has  been 
demonstrated  that  metastasis  takes  place  most  frequently 
by  direct  continuity  of  tissue  into  the  broad  ligament.  As 
a  matter  of  fact  just  as  wide  a  dissection  can  be  made  of 
the  broad  ligaments  by  the  vaginal  as  by  the  abdominal 
route.  In  only  about  thirteen  per  cent  of  all  cases  are  the 
removable  pelvic  glands  alone  involved.  It  is  impossible 
to  tell  by  macroscopical  examination  whether  the  glands 
are  involved  or  not.  Many  glands  that  are  seen  to  be  en- 
larged are  not  cancerous,  but  the  enlargement  is  due  to 
a  bacterial  infection.  Many  glands  not  materially  enlarged 
may  be  proved  by  microscopical  examination  to  be  can- 


160  CAECINOMA    OF    THE    UTEEUS 

cerous.  When  the  most  radical  operation  is  done  there 
always  remains  a  doubt  as  to  whether  all  the  infected  glands 
have  been  removed.  Small  cancerous  glands  in  the  pelvis 
are  easily  overlooked  and  no  attempt  is  made  to  remove 
the  abdominal  glands  into  which  a  portion  of  the  uterine 
lymphatics  directly  drain.  Up  to  the  present  time  the 
mortality  due  to  the  extensive  dissection  made  necessary  by 
the  attempt  to  remove  infected  glands  has  remained  very 
high.  This  high  operative  mortality  more  than  counter- 
balances the  permanent  recoveries  secured  by  the  removal 
of  the  pelvic  glands.  For  these  reasons  it  is  believed  that 
there  is  no  advantage  in  the  abdominal  over  the  vaginal 
hysterectomy,  except  when  there  are  adhesions  due  to  in- 
fection or  when  there  are  other  pelvic  growths,  either  uterine 
or  ovarian,  that  cannot  be  dealt  with  through  the  vagina. 

The  patient  is  put  in  the  Trendelenburg  position.  An 
abdominal  incision  is  made  in  the  median  line  from 
close  to  the  symphysis  to  a  point  high  enough  up  on  the 
abdomen  to  give  abundance  of  room.  The  intestines  are 
packed  off.  The  broad  ligaments  are  clamped  and  opened. 
The  bladder  is  separated  from  the  uterus.  The  ureters  are 
isolated.  The  uterine  arteries  are  clamped  close  to  their 
origin.  The  lower  portions  of  the  broad  ligaments  are  cut 
through  as  near  the  pelvic  wall  as  possible.  An  incision  is 
carried  through  the  vaginal  wall  around  the  cervix,  leaving 
a  wide  cuff  of  vagina  attached  to  the  cervix.  The  uterus  is 
then  removed.  The  ovarian  arteries  in  the  upper  portions  of 
the  broad  ligaments  are  tied.  The  uterine  arteries  are  tied. 
It  is  sometimes  necessary  to  put  a  running  over-and-over 
stitch  around  the  cut  borders  of  the  vaginal  wall  to  control 
the  bleeding  from  the  small  vaginal  vessels.  A  stitch  is  put 
into  the  lateral  walls  of  the  vagina  on  each  side  and  carried 
through  the  stump  of  the  corresponding  broad  ligament. 
This   stitch  assists   in  covering  over  the   denuded  areas 


TREATMENT  1G1 

and  prevents  a  subsequent  prolapse  of  the  vagina.  The  raw 
surfaces  are  then  covered  over  with  peritoneum.  A  pack 
is  pushed  down  through  the  opening  into  the  vagina  and 
enough  of  it  left  in  the  pelvis  to  prevent  the  intestines  from 
coming  down  in  contact  with  the  opening. 


CHAPTEE   XIII 

SARCOMA,     CHORIO-EPITHELIOMA,     SUBINVOLUTION,     AND     SUPER- 
INVOLUTION    OF    THE    UTERUS 

SARCOMA   OF   THE   UTERUS 

Sarcoma  is  a  malignant  growth  developing  from  con- 
nective tissue.    It  may  occur  at  any  age. 

Pathology.  —  Sarcoma  may  begin  either  in  the  stroma 
cells  of  the  endometrium  or  in  the  fibrous  connective  tissue 
in  the  uterine  wall.  Sometimes  it  is  present  as  a  diffuse 
growth.  This  is  particularly  apt  to  occur  when  it  has 
developed  from  the  stroma  cells  of  the  endometrium.  When 
it  develops  from  the  uterine  wall  it  usually  forms  a  rounded 
tumor.  Sarcoma  also  develops  in  uterine  fibroids.  When 
it  develops  in  a  uterine  fibroid  it  involves  not  only  the 
connective  tissue,  but  also  the  muscle  cells.  Sarcoma  of  the 
uterus  may  be  made  up  of  round  cells,  spindle  cells,  or  a 
mixture  of  these  two  varieties.  The  round-cell  sarcoma 
is  made  up  of  round  cells  having  relatively  large  nuclei  and 
a  limited  amount  of  protoplasm.  A  spindle-cell  sarcoma 
is  composed  of  large  and  small  elongated  cells  arranged  in 
bundles.  A  cross  section  of  these  spindle  cells  may  appear 
as  round  cells.  Two  or  more  nuclei  are  seen.  The  amount 
of  chromatin  in  the  sarcoma  cells  is  variable.  There  is  a 
variable  amount  of  connective  tissue  framework  distributed 
throughout  the  growth.  The  newly  formed  blood-vessels  are 
abundant.    The  secondary  changes  of  sarcoma  do  not  begin 

162 


CHORIO-EPITHELIOMA  163 

so  early  and  are  not  so  frequent  as  in  carcinoma,  because 
the  sarcoma  cells  have  a  rich  and  direct  blood  sup- 
ply. Metastasis  is  by  way  of  the  blood  and  lymphatic 
vessels. 

Symptoms.  —  The  symptoms  produced  by  sarcoma  are 
usually  the  same  as  those  caused  by  carcinoma,  hemorrhage 
and  pain.  Later  when  it  becomes  necrotic  there  is  a  bloody 
foul-smelling  discharge. 

Diagnosis.  —  The  tumor  mass  is  softer  than  that  of  an 
ordinary  fibroid.  Sometimes  it  forms  a  rounded  mass  that 
projects  through  the  cervix.  It  is  soft  on  palpation  and 
large  blood-vessels  are  seen  crossing  over  its  surface.  As 
a  rule  the  diagnosis  is  not  made  until  after  removal. 

Treatment.  —  The  treatment  is  a  complete  vaginal  or  ab- 
dominal hysterectomy. 


CHORIO-EPITHELIOMA 

(Deciduoma  Malignum,  Syncytloma  Malhgnum) 

Pathology.  —  Chorio-epithelioma  is  a  malignant  tumor 
which  develops  from  the  syncytial  cells  and  the  Langhan's 
cells  of  the  chorion  (Fig.  83).  In  the  majority  of  instances 
the  growth  is  preceded  by  an  hydatiforni  mole,  but  it  may 
develop  after  a  normal  pregnancy  that  has  terminated  either 
at  full  term  or  in  a  miscarriage.  The  original  tumor  is 
usually  found  in  the  uterine  wall,  but  occasionally  a  case 
is  met  with  in  which  no  uterine  growth  can  be  demonstrated. 
It  forms  a  soft  reddish  friable  mass.  On  microscopical 
examination  there  are  found  numerous  large  clear  cells 
with  vesicular  nuclei  and  masses  of  protoplasm  which  con- 
tain a  few  deeply  staining  nuclei.  The  individual  cells  are 
derived  from  the  Langhan's  layer  and  the  protoplasmic 
masses  from  the  syncytium  (Fig.  84).    Making  up  a  large 


164 


SAECOMA,    CHOKIO-EPITHELIOMA,    ETC. 


part  of  the  bulk  of  the  tumor  are  large  unlined  spaces  filled 
with  blood.  There  is  an  entire  absence  of  formed  vessels. 
On  account  of  the  erosive  action  of  the  chorionic  epi- 
thelium these  growths  readily  penetrate  the  walls  of  the 
blood-vessels  of  the  uterus,  and  entering  the  general  circu- 
lation, are  carried  to  all  parts  of  the  body.     This  results 


Fig.  83.  —  Chorionic  Villi.    (Photomicrograph.) 


in  the  very  early  development  of  metastatic  growths  in  the 
vagina,  kidneys,  liver,  lungs,  brain,  and  other  parts  of 
the  body.  The  metastatic  growths  are  similar  in  gross  ap- 
pearance and  identical  histologically  with  the  original 
growth.  All  chorio-epitheliomata  break  down  earlier  than 
other  malignant  growths. 

Symptoms.  —  The  most  important  symptom  is  a  more  or 
less  continuous  hemorrhage  from  the  uterus  that  dates  from 


CHOEIO-EPITIIELIOMA  165 

the  passage  of  a  uterine  mole,  a  labor,  or  a  miscarriage. 
The  blood  is  somewhat  modified  by  the  mixture  from  the 
necrotic  areas.  A  curettement  does  not  permanently  control 
the  bleeding. 

Prognosis.  —  If  removed  early  and  before  metastasis  has 
taken  place,  there  is  a  possibility  of  permanent  recovery. 


Fig.  84.  —  Chorio-epithelioma.     (Photomicrograph.) 

In  the  cases  where  metastasis  has  taken  place,  the  progress 
is  rapid  and  the  termination  is  always  fatal.  The  whole 
period  covered  by  the  disease  is  rarely  more  than  six 
months. 

Treatment.  —  As  soon  as  the  diagnosis  is  made  a  complete 
hysterectomy  should  be  done. 


166  SAECOMA,    CHOKIO-EPITHELIOMA,    ETC. 

SUBINVOLUTION 

Subinvolution  of  the  uterus  is  a  failure  of  the  uterus 
to  return  to  its  proper  size  after  the  termination  of 
pregnancy. 

Pathology.  —  There  is  usually  a  low  grade  of  infection  of 
the  endometrium  and  the  uterine  wall.  Frequently  asso- 
ciated with  this  infection  are  lacerations  of  the  cervix, 
retrodisplacement  of  the  uterus,  laceration  of  the  perineum, 
or  salpingitis. 

Symptoms.  —  There  is  a  history  of  a  comparatively  recent 
labor.  The  patient  complains  of  pain  in  the  back  and  a 
sense  of  weight  and  dragging  in  the  pelvis.  There  is  a 
leucorrheal  discharge.    The  menstrual  flow  is  increased. 

Diagnosis.  —  On  bimanual  examination  the  uterus  is 
found  to  be  uniformly  enlarged.  It  is  firm  on  pressure  and 
usually  somewhat  tender.  When  there  is  no  involvement 
of  the  tubes  the  uterus  is  movable.  The  condition  is  most 
likely  to  be  confused  with  a  small  fibroid  or  an  early  preg- 
nancy. When  the  enlargement  of  the  uterus  is  due  to  a 
fibroid,  usually  there  will  not  be  a  history  of  a  recent  preg- 
nancy. The  cervix  will  not  be  enlarged  in  proportion  to 
the  body,  and  in  nearly  all  cases  a  more  or  less  definite 
rounded  mass  indicating  the  position  of  the  fibroid  can  be 
felt.  In  early  pregnancy  there  will  be  an  absence  of  menses. 
Usually  there  is  morning  sickness.  The  breasts  will  be  en- 
larged and  tender  on  pressure;  the  papillae  around  the 
nipples  become  prominent,  the  veins  in  the  breasts  are 
enlarged,  and  there  may  be  some  slight  secretion  from  the 
breasts.  The  cervix  is  hard  except  just  around  the  external 
os,  where  it  is  softened  and  has  a  velvety  feel.  The  body 
of  the  uterus  is  globular  and  feels  like  a  cyst.  There  is 
some  discoloration  of  the  vagina  and  cervix. 


SUPEKINTOLUTION    OF    THE    UTERUS  167 

Treatment.  —  In  many  cases  all  that  is  necessary  in  the 
treatment  of  subinvolution  is  to  put  the  patient  in  bed. 
Glycerin  tampons,  to  deplete  the  congestion  of  the  uterus, 
and  hot  vaginal  douches  are  useful.  When  these  measures 
fail,  involution  may  be  promoted  by  thorough  curettement. 
When  there  are  lacerations  of  the  cervix  or  perineum,  it  is 
necessary  to  repair  them. 

SUPERINVOLUTION   OF   THE   UTERUS 

When  the  process  of  involution  after  labor  goes  on  until 
the  uterus  is  reduced  much  below  its  normal  size  it  is  said 
to  be  in  a  condition  of  superinvolution.  This  occurs  rarely, 
but  the  uterus  is  left  in  about  the  same  condition  as  when 
it  has  failed  to  develop  and  has  associated  with  it  very 
much  the  same  symptoms  as  are  associated  with  the  con- 
genially defective  uterus.  The  menses  are  usually  dimin- 
ished and  very  painful. 


CHAPTER    XIV 

UTERINE    FIBROIDS 

The  uterine  fibroid,  fibromyoma,  or  myoma  is  a  benign 
tumor  originating  in  the  uterine  wall  and  made  up  of  the 
same  histological  elements,  connective  tissue  and  unstriped 
muscular  fibers,   that  make  up  the  normal  uterine  wall. 


Fig.  85.  —  Multiple  Fibroids.     A,  external  os;  B,  internal  os;  C,  cervical 
fibroid;  D,  submucous  fibroid;  E,  subperitoneal  fibroid. 


There  are  connective  tissue  and  muscular  fibers  present 
in  all  these  tumors,  but  their  relative  proportions  vary 
widely.  When  connective  tissue  makes  up  the  bulk  of  the 
tumor  it  is  called  a  fibroid.  When  muscular  tissue  pre- 
dominates it  is  called  a  myoma.  When  there  is  a  more 
equal  distribution  of  the  two  tissues,  the  term  ''fibro- 
myoma "  is  used.     An  adeno-fibroma  has  growing  within 

168 


CLASSIFICATION 


169 


it  glands  that  are  an  extension  from  and  only  a  slight  modi- 
fication of  the  normal  uterine  glands.  The  term  ' '  fibroid  ' ' 
is  the  one  that  is  generally  used  in  referring  to  this  class 
of  tumors. 

Classification  According  to  Position.  —  According  to  their 
relation  to  the  uterine  wall,  fibroids  are  spoken  of  as  sub- 
peritoneal, submucous,  interstitial,  interligamentous,  and 
cervical. 


Fig.  86.  —  Submucous  Fibroid. 


A  subperitoneal  fibroid  is  one  that  is  situated  just  beneath 
the  peritoneum. 

A  submucous  fibroid  is  one  that- grows  just  beneath  the 
mucosa. 

An  interstitial  fibroid  is  one  that  is  located  in  the  uterine 
wall  about  the  same  distance  from  the  peritoneum  as  it  is 
from  the  mucosa. 

An  interligamentous  fibroid  is  one  that  has  developed 
from  one  side  of  the  uterus  and  grows  out  between  the  layers 
of  the  broad  ligaments. 

A  cervical  fibroid  is  one  that  has  developed  from  the 


170  UTERINE    FIBROIDS 

cervix.  When  a  cervical  fibroid  develops  just  beneath  the 
peritoneum  of  the  posterior  cervical  wall,  it  is  sometimes 
called  a  retroperitoneal  fibroid. 

Pathology.  —  All  fibroids  begin  to  develop  in  the  mus- 
cular wall  of  the  uterus.  The  tumors  in  which  fibrous  con- 
nective tissue  predominates  are  firm,  white,  rounded  masses 
of  extremely  variable  size  that  do  not  infiltrate  but  push 


Fig.  87.  —  Fibroid  Polypus. 

aside  the  tissues  of  the  uterine  wall.  The  displaced  uterine 
tissues  form  the  so-called  capsule  from  which  the  tumor 
can  be  readily  separated.  The  blood  supply  is  almost 
entirely  in  the  capsule.  The  vessels  that  penetrate  the 
tumor  are  very  insignificant. 

Contractions  of  the  uterine  muscular  fibers  cause  these 
tumors  to  migrate  in  the  direction  of  least  resistance.  As 
a  result  of  this  migration  tumors  that  were  originally  inter- 
stitial may  become  either  submucous  or  subperitoneal,  and 
a  continuation  of  the  migration  converts  sessile  submucous 
and  subperitoneal  tumors  into  pedunculated  tumors.     In 


PATPIOLOGY  171 

exceptional  cases  both  submucous  and  subperitoneal  tumors 
become  entirely  detached  from  the  uterus.  The  detached 
submucous  tumor  may  be  forced  entirely  out  of  the  vagina. 
The  detached  subperitoneal  fibroid  may  undergo  necrosis, 
but  usually  it  becomes  attached  to  some  of  the  abdominal 
viscera  from  which  it  receives  a  blood  supply. 

The  myomata  grow  more  intimately  with  the  uterine  tis- 
sues and  have  little  or  no  tendency  to  form  a  capsule.    The 


Fig.  88.  —  Subperitoneal  Fibroid. 

adeno-fibromyomata  cannot  be  readily  separated  from  the 
surrounding  tissues  in  which  they  grow.  In  the  myomata 
and  the  adeno-fibromyomata  which  have  no  capsule  the 
blood  supply  to  the  tumor  is  much  more  abundant  than  in 
the  connective  tissue  tumors. 

In  practically  all  cases  of  uterine  fibroids  the  ovarian 
and  uterine  arteries  are  enlarged  and  the  uterine  muscu- 
laris  and  mucosa  are  hypertrophied.  The  depth  of  the 
uterine  canal  is  increased.  Large  varicose  veins  develop 
in  the  broad  ligaments.    The  ovaries  are  frequently  hyper- 


172  UTEEINE    FIBEOIDS 

trophied.  The  tubes  are  frequently  enlarged,  but  not  other- 
wise changed  unless  they  are  infected.  Microscopically 
it  is  seen  that  the  cell  elements  of  the  tumor  are  the  same 
as  the  normal  uterine  wall.  The  unstriped  fusiform  muscle 
fibers  have  a  tendency  to  be  arranged  in  whorls  (Fig.  89). 
The  proportion  of  the  fibrous  connective  tissue  to  the  mus- 
cular tissue  varies  greatly.     The  firm,  hard,  white  tumors 


Fig.  89.  —  Fibromyoma.     (Photomicrograph.) 

that  develop  very  slowly  are  composed  almost  entirely  of 
fibrous  tissue.  The  soft  reddish  colored,  rapidly  growing 
tumors  are  made  up  almost  entirely  of  muscular  fibers. 
Between  these  two  extremes  there  is  found  every  possible 
variation  and  combination  of  muscular  and  fibrous  tissue. 
The  adeno-fibromyoma  is  a  growth  that  seems  to  be 
due  to  the  penetration  into  the  uterine  wall  of  typical 
glands  from  the  endometrium  and  the  formation  around 


PATHOLOGY 


173 


these  invading  glands  of  an  excess  of  fibrous  tissue 
(Fig.  90). 

Secondary  Pathological  Changes.  —  These  changes  in- 
clude fatty,  hyaline,  cystic,  and  calcareous  degeneration; 
septic  infection;   sarcoma;   and  carcinoma. 

Fatty  degeneration  affects  the  muscle  fibers  and  may  com- 
pletely destroy  them,  leaving  behind  only  the  contracting 


Fig.  90.  —  Adeno-fibromyoma.     (Photomicrograph.) 


fibrous  tissue.    This  is  the  process  that  takes  place  when 
fibroids  spontaneously  decrease  in  size. 

Hyaline  degeneration  takes  place  in  practically  all 
fibroids.  In  the  earlier  cases  the  hyaline  changes  may  be 
recognizable  only  by  the  microscope.  Later  large  areas 
are  involved  and  may  be  recognized  by  the  naked  eye. 
The  hyaline  areas  are  almost  devoid  of  cell  elements.  As 
the  process  goes  on  some  of  these  hyaline  areas  liquefy, 


174 


UTERINE    FIBROIDS 


resulting  in  the  formation  of  fluid-filled  cavities.  This  con- 
dition is  ordinarily  recognized  as  cystic  degeneration  of  a 
fibroid.  There  is  also  a  rarer  form  of  cystic  degeneration 
resulting  from  the  accumulation  of  fluid  in  the  lymph 
channels. 

Calcareous  degeneration  consists  of  the  deposit  of  lime 
salts  within  the  tumor.     It  is  secondary  to  a  diminished 


Fig.  91.  —  Fibroid  Undergoing  Cystic  Degeneration. 

blood  supply  and  is  most  frequently  seen  in  pedunculated 
subperitoneal  fibroids. 

When  the  blood  supply  to  a  submucous  fibroid  is  cut  off, 
it  undergoes  necrosis.  Along  with  this  necrotic  process 
there  is  usually  an  infection  not  only  of  the  tumor,  but  of 
the  tissues  from  which  the  tumor  has  become  detached. 
This  is  an  extremely  dangerous  complication. 

Sarcoma  develops  in  from  one  to  four  per  cent  of  all 
fibroids.  The  operators  who  have  had  their  specimens 
most  carefully  examined  have  found  the  highest  percentage 


PATHOLOGY 


175 


of  sarcoma.  Ordinarily  it  develops  in  only  one  nodule  of  a 
fibroid.  Sarcomatous  areas  are  usually  sharply  defined 
(Fig.  92).  They  can  usually  be  recognized  by  the  yellow- 
ish white  tissue  that  is  almost  devoid  of  fibrous  elements. 
The  central  portion  of  the  sarcomatous  part  of  the  tumor 
undergoes  quite  early  a  coagulation  necrosis,  followed  by 


Fig.  92.  —  Fibrosarcoma.     (Photomicrograph.)     Sarcoma  developing  in  a 
fibroid  tumor.    A,  fibroid;   B,  sarcoma. 

liquefaction.  The  resulting  cysts  may  be  of  considerable 
size.  The  sarcomatous  growth  may  be  limited  for  a  long 
time  to  its  original  point  of  starting,  but  later  secondary 
nodules  become  scattered  throughout  the  uterine  walls,  or 
project  as  polypi  into  the  uterine  cavity.  Sarcomata  de- 
veloping in  fibroid  tumors  may  develop  either  directly  from 
the  connective  tissue  cells  or  from  the  muscle  cells. 

Carcinomata  of  the  uterus  are  sometimes  associated  with 


176  UTERINE    FIBROIDS 

fibroids,  but  it  is  difficult  to  establish  any  definite  relation 
between  the  two  growths.  The  carcinoma  may  be  of  the 
squamous  cell  variety  of  the  cervix  or  an  adeno-carcinoma 
developing  from  the  endometrium.  It  is  improbable  that 
there  is  any  definite  relation  between  the  squamous  cell 
carcinoma  of  the  cervix,  and  the  associated  fibroid.  It  has 
been  noted  that  adeno-carcinomata  are  met  with  more  fre- 
quently in  association  with  submucous  fibroids  than  when 
no  fibroids  are  present.  An  adeno-carcinoma  does  not  start 
on  the  part  of  the  mucous  membrane  directly  over  the 
fibroid,  but  as  a  rule  on  the  opposite  uterine  wall  where 
the  pressure  from  the  fibroid  is  greatest.  It  is  reasonable 
to  suppose  that  this  pressure  from  the  fibroid  has  some- 
thing to  do  with  starting  the  growth.  There  is  the  possi- 
bility of  a  carcinoma  starting  from  the  epithelium  of  the 
glands  in  an  adeno-fibromyoma. 

Rate  of  Growth.  —  Generally  speaking  the  rate  of  growth 
of  fibroid  tumors  is  slow.  Those  that  are  made  up  most 
largely  of  muscular  elements  develop  most  rapidly.  Hard 
fibrous  tumors  develop  very  slowly.  It  is  impossible  to 
predict  with  any  accuracy  the  rate  of  development  of  any 
given  fibroid.  One  that  has  been  present  and  has  been 
known  to  be  developing  very  slowly  may  suddenly  begin 
to  grow  and  enlarge  with  great  rapidity.  On  the  other  hand 
many  fibroids  will  go  on  growing  slowly  for  several  years, 
and  then  entirely  stop  increasing  in  size.  When  a  fibroid 
that  has  been  growing  slowly  begins  to  develop  with  un- 
usual rapidity,  this  increase  in  size  may  be  due  to  the  rapid 
increase  of  its  muscular  elements,  but  it  is  very  often  due 
to  sarcoma. 

Period  of  Growth.  —  Fibroids  develop  during  the  men- 
strual life  of  women.  They  are  rare  before  the  age  of 
twenty,  and  it  is  no  doubt  very  unusual  for  them  to  begin 
to  develop  after  the  age  of  forty-five.     The  largest  num- 


COMPLICATIONS  1 i 1 

ber  of  fibroids  are  seen  in  women  in  the  decade  from  thirty 
to  forty.  It  has  long  been  taught  that  after  the  establish- 
ment of  the  menopause,  fibroids  undergo  fatty  degeneration 
and  gradual  absorption.  This  is  true  in  some  cases,  but 
in  very  many  instances  fibroids  continue  to  increase  in  size 
and  may  even  increase  in  size  at  a  much  more  rapid  rate 
after  the  establishment  of  the  menopause  than  previously. 
Such  a  small  percentage  of  women  are  relieved  of  the  symp- 
toms produced  by  fibroids  by  the  establishment  of  the  meno- 
pause that  it  is  unwise  to  advise  these  patients  to  postpone 
operative  relief  in  the  hope  that  with  the  establishment  of 
the  menopause  they  will  have  no  further  trouble. 

Number.  —  There  is  apparently  no  limit  to  the  number 
of  fibroids  that  may  develop  in  a  uterus.  Very  frequently 
there  is  only  one,  but  multiple  fibroids  up  to  a  dozen  are 
common.  As  many  as  forty  have  been  found  in  a  single 
uterus.  Ordinarily  the  fibrous  tissue  appears  in  perfectly 
definite,  localized  nodules.  Occasionally  there  is  a  growth 
of  fibrous  tissue  throughout  the  whole  uterus. 

Size.  —  Fibroids  vary  in  size  from  a  microscopic  point 
up  to  the  size  of  a  full-term  pregnancy.  Fibroids  large 
enough  to  fill  the  pelvis  and  project  half-way  to  the  um- 
bilicus are  comparatively  common.  Enormously  large  ones 
are  very  rare. 

Complications  of  Fibroids.  —  One  of  the  most  frequent 
complications  of  fibroid  tumors  is  infection  of  the  tubes. 
This  infection  may  result  in  extensive  adhesions  that  bind 
the  tumor  firmly  in  the  pelvis  and  greatly  increase  the  diffi- 
culty of  operation.  Abscess  cavities,  also,  may  result  from 
the  infected  tubes,  increasing  very  materially  the  hazard 
of  operation  for  the  removal  of  the  fibroids.  Where  there 
is  an  accumulation  of  much  pus  and  it  is  possible  to  do  so, 
it  is  best  to  drain  the  abscess  cavity  through  the  posterior 
vaginal  wall  some  weeks  before  any  attempt  is  made  to 


178  UTEKINE    FIBKOIDS 

remove  the  fibroid.  Infection  of  the  tubes  is  a  contra- 
indication for  myomectomy.  Supravaginal  hysterectomy 
with  drainage  through  the  posterior  vaginal  wall  is  the 
operation  that  is  applicable  to  most  of  these  cases. 

The  ureters  may  be  displaced  or  obstructed  by  the  growth 
of  fibroids.  The  obstruction  may  result  in  dilatation  of 
the  ureter  and  of  the  pelvis  of  the  kidney. 

Uterine  displacements  may  result  from  the  position  of 
the  growth.  A  relatively  small  fibroid  growing  either  an- 
teriorly or  posteriorly  in  the  body  of  the  uterus  near  the 
fundus  may  cause  a  retrodisplacement.  Large  fibroids 
growing  out  into  the  broad  ligaments  will  push  the  uterus 
to  the  opposite  side  of  the  pelvis.  A  submucous  fibroid 
occasionally  produces  inversion. 

Fibroids  and  Pregnancy.  —  Submucous  fibroids  as  a  rule 
cause  sterility.  A  pregnancy  may  take  place  when  fibroids 
are  present  so  long  as  the  cavity  of  the  uterus  is  not  ma- 
terially affected.  Pregnancy,  of  course,  is  most  frequently 
seen  associated  with  subperitoneal  fibroids,  but  much  more 
serious  is  a  pregnancy  complicated  by  a  large  cervical 
fibroid  that  obstructs  the  pelvic  canal. 

Pregnancy  in  connection  with  fibroids  can  usually  be 
recognized  by  the  cessation  of  the  menses,  the  rapid  in- 
crease in  size  of  the  tumor,  and  the  other  signs  of  preg- 
nancy. In  dealing  with  this  complication  each  case  must 
be  judged  separately.  In  a  very  large  proportion  there  is 
no  occasion  to  interfere.  In  some  of  the  larger  subperi- 
toneal tumors  an  abdominal  myomectomy  may  be  done  to 
advantage.  In  exceptional  cases  it  may  be  advisable  to 
do  a  hysterectomy  in  spite  of  the  pregnancy.  A  pregnancy 
complicated  by  a  large  cervical  fibroid  may  be  allowed  to 
go  to  a  full  term,  when  the  child  can  be  delivered  by 
Csesarean  section  or  by  a  Porro  operation. 

Symptoms.  —  Hemorrhage  is  the  most  common  symptom 


DIAGNOSIS  179 

of  fibroids.  The  submucous  variety  gives  rise  to  the  great- 
est amount  of  bleeding.  The  interstitial  produces  little 
hemorrhage  and  the  subperitoneal  usually  causes  none. 
The  hemorrhage  generally  begins  as  a  slightly  increased 
flow  at  the  menstrual  period.  The  length  of  the  periods 
is  gradually  increased  until  in  some  cases  there  is  an  almost 
continuous  flow.  The  quantity  of  the  blood  lost  at  any  one 
time  is  usually  not  large,  but  the  persistence  of  the  flow 
may  be  sufficient  to  produce  a  grave  anemia.  Exceptionally 
there  will  be  a  sudden  flow  of  blood  sufficient  to  cause  faint- 
ing. The  adeno-flbromyomata  usually  cause  very  profuse 
hemorrhages.  The  conditions  that  favor  hemorrhage  when 
submucous  fibroids  are  present  are  the  blood  supply  in  the 
capsule  of  the  tumor,  the  presence  of  an  hypertrophic  endo- 
metrium, and  the  inability  of  the  uterus  on  account  of  the 
presence  of  the  tumor  to  contract  upon  the  bleeding  point. 

Pain  is  a  common  but  not  a  constant  symptom  of  fibroids. 
Sometimes  it  is  due  to  the  contraction  of  the  uterus  on  the 
tumor.  Pain  due  to  this  cause  is  intermittent.  Ordinarily 
the  discomfort  complained  of  is  a  sense  of  pressure  and 
weight  in  the  pelvis  with  pain  in  the  back.  The  pain  is 
increased  at  the  menstrual  period.  A  sudden  increase  of 
pain  and  tenderness  indicates  that  some  new  pathological 
process  has  been  lighted  up.  Leucorrhea  is  present  in  the 
same  class  of  cases  that  have  hemorrhage.  It  is  most 
marked  during  the  congestion  of  the  endometrium  just 
before  and  just  after  the  menstrual  periods.  Frequent  uri- 
nation is  present  in  those  cases  in  which  the  tumor  is  in 
such  a  position  that  it  presses  on  the  base  of  the  bladder, 
or  when  the  capacity  of  the  bladder  is  restricted.  Consti- 
pation, hemorrhoids,  and  occasionally  rectal  tenesmus  re- 
sult from  pressure  on  the  lower  bowel. 

Diagnosis.  —  Fibroids  that  are  large  enough  to  project 
above  the  brim  of  the  pelvis  can  be  detected  by  abdominal 


180 


UTEKINE    FIBKOIDS 


examination.  When  the  patient  is  in  the  recnmbent  position 
it  is  noted  by  inspection  that  the  lower  portion  of  the 
abdominal  wall  is  elevated  above  the  level  of  the  line  run- 
ning from  the  symphysis  to  the  ensiform  appendix.  The 
elevated  area,  being  due  to  a  tumor  that  is  very  slightly 
compressible,  is  often  very  sharply  defined.  Above  this 
area  the  line  of  the  abdominal  wall  drops  abruptly  to  near 
the  level  of  the  ensiform  appendix.  The  portion  of  the 
abdominal  wall  between  the  ensiform  appendix  and  the 
highest  point  of  the  tumor  rises  and  falls  with  each  inspira- 


Fig.  93.  —  Outline  of  Abdomen  Containing  a  Large  Fibroid. 

tion  and  expiration,  while  the  portion  of  the  abdominal  wall 
from  the  highest  point  of  the  tumor  to  the  symphysis  re- 
mains almost  stationary.  There  is  an  absence  of  pigmen- 
tation in  the  median  line  of  the  abdomen.  The  breasts  are 
not  enlarged,  and  there  is  an  absence  of  pigmentation 
around  the  nipples  and  no  enlargement  in  the  veins  of  the 
breasts.  There  is  an  absence  of  secretion  in  the  breasts.  On 
palpation  a  rounded  or  nodular  firm  tumor  can  be  felt  rising 
from  the  pelvis.  The  rapidly  growing  myomata  or  fibro- 
myomata  which  have  undergone  extensive  cystic  degener- 
ation may  feel  so  soft  as  to  be  indistinguishable  by  palpa- 
tion from  a  pregnant  uterus  or  from  an  ovarian  cyst.     On 


TREATMENT  181 

percussion  the  elevated  portion  of  the  abdominal  wall  is 
dull.  The  intestines  lie  above  and  to  the  sides  of  the 
growth.  The  percussion  note  over  them  is  tympanitic. 
As  a  rule  the  only  point  gained  on  auscultation  is  negative ; 
that  is,  the  absence  of  fetal  heart  sounds. 

On  bimanual  examination  a  hard  uterine  tumor  can  be 
made  out.  It  is  usually  easily  movable  and  the  cervix 
moves  with  the  tumor.  If  there  is  an  associated  salpingitis, 
the  resulting  adhesions  limit  the  mobility.  The  essential 
thing  to  make  out  ordinarily  is  that  the  tumor  present  is 
a  uterine  growth  and  that  it  is  hard.  The  exceptional  soft 
fibroid  which  evenly  enlarges  the  uterus  can  be  distin- 
guished from  a  pregnancy  by  the  history  of  irregular  or 
increased  menstruation  and  by  the  absence  of  all  other 
signs  of  pregnancy.  In  cases  of  doubt  the  patient  should 
be  kept  under  observation  for  a  few  weeks  when  the  re- 
currence of  the  menses  or  their  absence,  with  the  rapid 
enlargement  of  the  tumor  and  the  development  of  other 
signs  of  pregnancy,  will  settle  the  question.  In  this  con- 
nection it  should  be  remembered  that  occasionally  a  fibroid 
and  a  pregnancy  are  found  in  the  same  uterus.  In  those 
cases  the  fibroid  does  not  usually  encroach  upon  the  uterine 
cavity  and  can  be  distinguished  almost  invariably  by  palpa- 
tion from  the  cystic  body  of  the  pregnant  uterus. 

Fibroid  polypi  may  frequently  be  felt  just  within  the 
dilated  cervival  canal  or  projecting  from  the  external  os. 
They  are  usually  smooth,  hard,  and  round. 

Treatment.  —  In  the  medical  treatment  of  fibroids,  one 
after  another  of  a  long  list  of  remedies  have  been  advo- 
cated, used,  and  abandoned.  A  few  years  ago  electricity 
was  brought  forward  as  a  sovereign  cure,  but  it  also  has 
joined  the  useless  group  of  non-surgical  measures.  It  is 
true  that  under  the  administration  of  drugs  and  the  appli- 
cation of  electricity  some  patients  are  apparently  relieved ; 


182  UTERINE    FIBROIDS 

but  when  we  recall  the  facts  that  the  rate  of  growth  of 
fibroids  is  very  irregular,  that  the  size  one  will  attain  before 
ceasing  to  grow  is  unascertainable,  that  the  migration  of 
the  tumor  may  cause  a  change  in  the  symptoms  produced, 
and  that  fatty  degeneration  may  begin  at  any  time  and 
cause  reduction  in  the  size  of  the  tumor,  it  is  easy  to  under- 
stand how  a  remedy  may  be  credited  with  a  change  for  the 
better  with  which  it  had  nothing  to  do. 

Since  we  have  to  rely  upon  operative  measures  for  any 
definite  results  in  the  treatment  of  fibroids,  the  question 
immediately  arises:  Shall  all  fibroids  be  removed?  At  the 
present  time  the  question  would  be  answered  by  the  ma- 
jority of  operators  about  this  way:  Any  fibroid  that  is 
growing  rapidly  or  that  is  causing  hemorrhage,  pain,  or 
pressure  symptoms  should  be  removed.  Conversely  any 
fibroid  which  is  not  large  enough  to  interfere  materially 
with  other  organs  by  pressure,  which  is  not  rapidly  en- 
larging, and  which  is  not  causing  pain  or  hemorrhage  may 
safely,  for  a  time  at  least,  be  allowed  to  remain,  but  must 
be  kept  under  observation. 

In  some  of  the  larger  tumors  which  have  caused  much  loss 
of  blood  and  which  will  necessitate  a  radical  operation,  a 
curettage  is  sometimes  done  as  a  preparatory  measure. 
The  curettage  checks  for  the  time  the  loss  of  blood  and 
allows  the  patient  to  recuperate  enough  to  withstand  the 
major  operation.  There  are  some  cases  of  small  submucous 
fibroids  which  cause  hemorrhage  and  which  are  best  treated 
by  one  or  more  thorough  curettements. 

Operations  for  the  removal  of  fibroids  are  done  either 
through  the  vagina  or  through  the  abdominal  wall.  By 
both  routes  fibroids  are  removed  either  by  myomectomy  or 
hysterectomy. 

Vaginal  myomectomy  is  applicable  to  the  pedunculated 
submucous  fibroids  or  polypi,  to  some  of  the  sessile  sub- 


TREATMENT  183 

mucous  tumors,  to  a  part  of  the  cervical  fibroids,  and  to 
some  of  the  smaller  tumors  in  the  body  of  the  uterus.  Many 
of  the  smaller  polypi  can  be  removed  by  grasping  them  with 
a  strong  vulsellum  and  twisting  them  until  the  pedicle  is 
broken  off.  When  the  pedicle  is  large  and  the  tumor  does 
not  fill  up  the  vagina,  it  may  be  drawn  down  and  the  pedicle 
cut  through  with  scissors.  If  the  tumor  is  so  large  that 
the  whole  vagina  is  filled,  making  it  difficult  or  impossible 
to  reach  the  pedicle,  the  tumor  may  be  removed  piecemeal 
and  the  pedicle  cut  through  after  the  bulk  of  the  tumor  is 
out  of  the  way.  There  is  practically  no  hemorrhage  from 
the  incisions  into  the  tumor  and  none  of  importance  from 
the  severed  pedicle. 

A  sessile  submucous  fibroid  that  is  not  too  large  and  that 
can  be  reached  either  by  dilating  or  splitting  the  cervix, 
can  be  removed  by  splitting  the  capsule  and  enucleating 
the  tumor  as  a  whole,  or  it  may  be  removed  piecemeal. 
Tumors  of  relatively  small  size  growing  in  the  body  of 
the  uterus  can  be  removed  after  the  uterus  is  brought  to 
the  outside  through  an  incision  in  the  anterior  vaginal  wall. 
The  tumors  are  enucleated,  the  wound  in  the  uterus  closed 
with  catgut,  the  uterus  is  returned  to  its  proper  position, 
and  the  wound  in  the  anterior  vaginal  wall  closed.  A 
vaginal  hysterectomy  is  applicable  only  to  the  uterus  that 
is  studded  with  small  fibroids  when  myomectomy  is  not 
practicable. 

The  abdominal  operation  which  is  done  most  frequently 
for  uterine  fibroids  is  supravaginal  hysterectomy.  A  me- 
dian abdominal  incision  is  made  sufficiently  long  to  allow 
the  tumor  to  be  brought  through  it.  The  incision  should 
be  carried  down  close  to  the  symphysis.  A  clamp  is  put 
on  the  broad  and  round  ligaments  of  one  side  and  a  second 
clamp  catches  the  broad  ligament  between  the  first  clamp 
and  the  uterus.     The  upper  part  of  the  broad  ligament  is 


184 


UTERINE    FIBEOIDS 


then  cut  through.  The  same  procedure  is  carried  out  on 
the  other  side.  An  incision  only  through  the  peritoneum 
is  carried  across  the  front  of  the  tumor  connecting  the  in- 
cisions in  the  broad  ligaments  (Fig.  94).  This  flap  of  peri- 
toneum on  the  anterior  uterine  wall  is  stripped  downward 
and  the  bladder  is  pushed  well  forward.  At  the  same  time 
the  layers  of  the  broad  ligaments  are  separated  and  the 


Fig.  94.  —  Supravaginal  Hysterectomy.  First  step.  Forceps  a,  a  clamp 
the  ovarian  arteries  and  the  round  ligaments  on  the  uterine  side  of  the  incision. 
Forceps,  b,  b  clamp  the  ovarian  arteries  and  the  round  ligaments  on  the  pelvic 
side  of  the  incision.  On  the  left  the  broad  ligament  has  been  cut  through  and  the 
clamp  c  is  on  the  uterine  artery.  The  dotted  line  indicates  the  line  of  incision 
through  the  broad  ligament  and  through  the  peritoneum  in  front  of  the  uterus. 


sides  of  the  cervix  exposed  down  close  to  its  vaginal  attach- 
ment. It  is  not  necessary  to  pay  much  attention  to  the 
peritoneum  posterior  to  the  tumor  and  uterus.  When  the 
sides  of  the  cervix  are  exposed  the  uterine  arteries  are 
clamped.  These  clamps  are  put  on  at  right  angles  to  the 
axis  of  the  cervix.  There  is  very  little  danger  of  injuring 
the  ureter  when  the  clamps  are  put  on  in  this  way.    When 


TREATMENT 


185 


both  uterine  arteries  have  been  clamped  the  cervix  is  cut 
through  just  above  the  clamps  and  the  tumor  removed 
(Fig.  95).  The  clamped  upper  border  of  the  broad  liga- 
ment with  the  ovarian  artery  is  then  ligated  on  each  side. 
This  ligature  can  usually  be  made  to  include  also  the  round 
ligament.  These  ligatures  are  left  long  temporarily  to 
serve  as  a  guide  to  the  stump  of  the  broad  and  round  liga- 
ments. The  uterine  arteries  are  next  ligated.  All  clamps 
are  removed  after  the  ligatures  are  in  place  but  just  before 


Fig.  95.  —  Supravaginal  Hysterectomy.  Second  step.  Both  broad  liga- 
ments have  been  cut  through  both  uterine  arteries  secured  by  clamps,  and  the 
cervix  is  partially  cut  through. 

they  are  drawn  tight.  A  ligature  is  then  passed  through 
the  wall  of  the  cervical  stump  on  each  side  of  the  canal  to 
control  the  small  vessels  in  the  cervical  wall.  After  this 
ligature  is  tied  the  needle  is  passed  through  the  stump  of 
the  broad  and  round  ligaments  on  the  same  side  and  tied 
a  second  time  (Fig.  96).  This  brings  the  severed  ends  of 
the  broad  and  round  ligaments  and  the  stump  of  the  cervix 
in  apposition,  helps  to  cover  the  raw  surfaces,  restores  the 


186  UTERINE    FIBROIDS 

support  of  the  vault  of  the  vagina,  and  prevents  prolapse. 
The  flap  of  peritoneum  previously  dissected  from  the  an- 
terior wall  of  the  tumor  is  then  stitched  over  the  stump 
of  the  cervix.  Any  gaps  in  the  broad  ligaments  are  closed 
and  the  floor  of  the  pelvis  made  as  smooth  as  possible. 
Unless  there  is  some  special  indication  the  abdomen  is 
closed  without  drainage. 

By  abdominal  myomectomy  is  meant  the  removal  of  uter- 


Fig.  96.  —  Supravaginal  Hysterectomy.  Third  step,  a  shows  the  method 
of  placing  a  suture  to  bring  the  stumps  of  the  round  and  broad  ligaments  to  the 
stump  of  the  cervix;   b  shows  the  corresponding  suture  tied. 

ine  fibroids  through  an  incision  in  the  abdominal  wall  with- 
out the  removal  of  the  uterus.  It  is  applicable  to  tumors 
in  any  location  in  the  uterus  when  they  are  not  too  numer- 
ous, and  when  the  uterine  wall  has  not  been  too  much 
disorganized  by  their  growth.  Naturally  the  pedunculated 
subperitoneal  fibroids  are  the  ones  most  easily  dealt  with, 
but  the  sessile  subperitoneal,  interstitial,  and  submucous 
may  also  be  removed  by  this  method.  From  this  it  would 
appear  that  a  large  portion  of  fibroids  could  be  removed  by 
myomectomy.  As  a  matter  of  fact,  each  case  must  be  judged 
by  itself,  and  the  result  is  that  only  a  relatively  small  per 
cent  of  them  can  best  be  treated  in  this  way.     The  two 


TREATMENT 


is; 


dangers  of  myomectomy  are  hemorrhage  and  sepsis.  Of 
these,  sepsis  has  been  responsible  for  the  greatest  amount 
of  trouble  following  this  operation.  When  the  operation 
was  first  introduced  the  mortality  from  sepsis  was  greater 
than  the  mortality  after  supravaginal  hysterectomy,  but  as 
operative  technique  has  improved  the  dangers  of  sepsis  have 
very  much  diminished  and  the  field  for  myomectomy  has 
consequently  broadened. 

In  the  removal  of  pedunculated  tumors  a  cuff  of  peri- 


Fig.  97.  —  Myomectomy. 

toneum  is  dissected  from  the  pedicle,  the  pedicle  cut 
through,  the  stump  ligated  in  sections,  and  the  cuff  of  peri- 
toneum stitched  smoothly  over  it.  In  the  tumors  having 
no  pedicle,  an  incision  parallel  to  the  long  axis  of  the  uterus 
is  made  directly  over  the  mass.  The  fibroid  is  separated 
from  its  capsule  by  blunt  dissection  and  removed  (Fig.  97). 
The  wound  is  closed  by  one  or  more  tiers  of  sutures  so 
placed  that  they  will  control  the  hemorrhage  and  coapt 
the  edges  of  the  wound.  These  sutures  must  not  be  drawn 
too  tightly.  Care  should  be  taken  to  handle  the  wound  as 
little  as  possible. 


CHAPTER   XV 

DISEASES     OF     THE     FALLOPIAN     TUBES     AND    PELVIC     CELLULITIS 

ANATOMY 

The  Fallopian  tubes  are  two  trumpet-shaped  organs  about 
four  and  a  half  inches  long  that  are  continuous  with  the 
superior  angles  of  the  uterus.  They  extend  outward  from 
the  uterus  between  the  layers  of  the  broad  ligament  at  its 
upper  border.  Internally  the  tubes  are  narrow  and  open 
into  the  cavity  of  the  uterus.  Externally  the  tubes  become 
wider  and  terminate  in  an  expanded  mouth  which  opens  into 
the  peritoneal  cavity.  The  internal  narrow  portion  of  the 
tubes  is  called  the  isthmus ;  the  outer  wider  part  is  called 
the  ampulla. 

The  tubes  are  made  up  of  four  coats,  —  serous,  cellular, 
muscular,  and  mucous.  The  serous  coat  is  the  free  border 
of  the  broad  ligament.  It  is  incomplete  below  where  the 
two  laminae  approximate  each  other.  The  cellular  coat 
is  continuous  with  the  subperitoneal  tissue  of  the  broad 
ligament  and  is  rich  in  blood-vessels.  The  muscular  coat 
is  about  one-sixth  of  an  inch  in  thickness.  It  is  directly 
continuous  with  the  muscular  wall  of  the  uterus.  The 
mucous  membrane  has  numerous  longitudinal  folds.  Near 
the  uterine  end  of  the  tube  (Fig.  98)  these  folds  are  ar- 
ranged very  simply,  but  as  the  outer  extremity  of  the  tube 
is  approached  the  folds  become  so  numerous  and  complex 
that  a  cross  section  gives  the  appearance  of  branching 
tubular  glands  in  the  mucosa    (Fig.   99).     The  folds   of 

188 


SALPINGITIS 


189 


mucous  membrane  projecting  from  the  ends  of  the  tubes 
terminate  irregularly  and  form  the  fimbriae  (Fig.  100).  The 
surface  of  the  mucosa  is  covered  with  a  single  layer  of 
columnar  epithelium. 


SALPINGITIS 

The  term  "  salpingitis  "  includes  all  the  changes  that 
take  place  in  the  Fallopian  tubes  as  the  result  of  infection. 


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Fig.  98.  —  Uterine  End  of  Fallopian  Tube.    (Photomicrograph.) 

Etiology.  —  There  are  numerous  organisms  that  occa- 
sionally infect  the  tubes,  but  the  ones  most  frequently 
present  are  the  gonococcus,  the  streptococcus,  and  the 
bacillus  tuberculosis.  The  tuberculous  infections  will  be 
taken  up  separately,  so  that  under  the  present  heading  only 
the  changes  due  to  the  gonococcus  and  other  pus-producing 


190     DISEASES    OF    THE    FALLOPIAN    TUBES,    ETC. 

organisms  will  be  considered.  A  very  large  percentage  of 
the  infections  following  labor  and  miscarriage  are  strepto- 
coccus infections.  The  vast  majority  of  the  non-puerperal 
infections  are  infections  by  gonococci. 

Pathology.  —  Infections  of  the  tubes  are  practically  al- 
ways a  direct  extension  from  an  infection  of  the  endo- 
metrium ;  consequently  salpingitis  is  usually  bilateral.    One 


Fig.  99.  —  Middle  of  Fallopian  Tube.    (Photomicrograph.)     The  many 
folds  in  the  mucous  membrane  of  the  Fallopian  tube  are  shown. 

of  the  early  results  of  infection  of  the  tube  is  the  sealing 
up  of  the  fimbriated  extremity.  Changes  taking  place  within 
the  tube  vary  with  the  kind  and  the  virulence  of  the 
infection.  What  are  known  as  the  different  varieties  of 
salpingitis  are  in  reality  only  different  stages  of  the 
same  process.  For  convenience  they  may  be  grouped  as 
follows :  catarrhal  salpingitis,  purulent  salpingitis,  pyosal- 


SALPINGITIS  191 

pinx,  interstitial  salpingitis,  hydrosalpinx,  and  tubo-ovarian 
abscess. 

In  catarrhal  salpingitis  the  infection  involves  only  the 
mucous  membrane  of  the  tube,  and  little  or  no  pus  is  formed. 
It  may  be  either  the  result  of  infection  in  its  early  stages 
or  the  result  of  an  infection  of  low  virulence.    Some  of  these 


"tv^.'Y 


Fig.   100.  —  Fimbriated   Extremity   of   Fallopian   Tube.     (Photomicro- 
graph.) 

cases  are  seen  before  there  has  been  enough  reaction  to  close 
the  ends  of  the  tube  or  to  start  a  peritonitis  causing  ad- 
hesions. There  is  very  little  increase  in  the  size  of  the 
tubes.  On  microscopical  examination  there  is  seen  much 
small  round-cell  infiltration  and  many  polynuclear  leuco- 
cytes in  the  mucosa.  The  epithelium  is  swollen.  The  blood- 
vessels of  the  mucous  membrane  are  congested.  There  may 
be  slight  round-cell  infiltration  in  the  wall  of  the  tube. 


192  DISEASES    OF    THE    FALLOPIAN"    TUBES 

By  purulent  salpingitis  is  meant  that  condition  in  which 
there  is  definite  pus  formation  in  the  tube  but  without  any 
great  accumulation  of  pus  (Fig.  102).  It  is  a  process  that 
is  a  little  farther  advanced  in  its  development  than  the 
catarrhal  form.  When  the  tube  becomes  widely  distended 
with  pus  it  is  called  a  pyosalpinx.  When  sections  of  infected 
tubes  are  examined  microscopically  every  step  in  the 
changes  from  those  seen  in  mild  catarrhal  cases  to  the  com- 
plete destruction  of  the  mucosa  are  seen. 

In  interstitial  salpingitis  the  reaction  to  the  infection  is 


Fig.  101.  —  Salpingitis.    This  is  one  of  the  types  of  gonorrheal  salpingitis. 

more  marked  in  the  walls  of  the  tube  than  in  the  mucous 
membrane  (Fig.  103).  It  may  be  associated  with  purulent 
salpingitis,  but  in  some  instances  the  infection  seems  to 
involve  the  walls  of  the  tube  primarily.  Cases  of  the  latter 
sort  are  usually  due  to  a  streptococcus  infection.  In  the 
early  stages  of  this  condition  the  most  obvious  process  is 
the  enormous  infiltration  of  small  round  cells.  In  the  later 
processes  the  walls  of  the  tube  become  many  times  thicker 
than  normal  from  an  increase  of  connective  tissue  and  the 
lumen  becomes  narrowed. 

Hydrosalpinx  is  a  tube  that  is  sealed  at  both  ends  and 
distended  with  a  thin  watery  fluid.     Hydrosalpinx  in  the 


SALPINGITIS 


193 


beginning  is  probably  due  to  a  mild  infection  which  con- 
tinues until  both  ends  of  the  tube  are  closed  but  which  does 
not  destroy  the  epithelium  of  the  mucosa.  When  the  in- 
flammatory process  has  stopped  the  epithelium  continues  to 
secrete,  but  both  ends  of  the  tube  being  closed  there  is  no 


Fig.  102.  —  Purulent  Salpingitis.  (Photomicrograph.)  Compare  the 
folds  in  the  mucous  membrane  of  the  tube  with  those  shown  in  Fig.  98.  Between 
the  folds  of  the  mucous  membrane  is  free  pus.    A,  swollen  mucosa;  B,  free  pus. 


avenue  for  the  escape  of  the  secretion,  and  it  gradually  dis- 
tends the  tube.  The  walls  of  a  hydrosalpinx  are  very  thin. 
Its  cavity  is  lined  with  epithelium  that  is  somewhat  lower 
than  the  normal  epithelium  found  in  the  tube,  and  here 
and  there  a  few  remains  of  the  folds  of  the  mucous  mem- 
brane of  the  tube  can  be  seen  (Fig.  105). 

A  tubo-ovarian  abscess  is  the  result  of  direct  infection  of 
the  ovary  from  the  tube  either  by  way  of  the  fimbriated 


194 


DISEASES    OF    THE    FALLOPIAN    TUBES 


extremity  or  directly  through  the  wall  of  the  tube.  As  its 
name  indicates,  it  is  an  abscess  cavity  the  walls  of  which 
are  made  up  partly  of  ovarian  tissue  and  partly  of  the 
walls  of  the  tube.  They  vary  greatly  in  size,  some  of  them 
forming  a  mass  large  enough  to  fill  up  the  entire  pelvis. 


Fig.    103.  —  Interstitial    Salpingitis.      (Photomicrograph.) 
infiltration  in  the  muscularis  of  the  tube  is  shown. 


Round-cell 


The  walls  of  the  abscess  are  usually  very  thick  and  resistant 
and  form  a  well-defined,  rounded  mass. 

As  the  result  of  leakage  from  the  end  of  the  tube  before 
its  closure,  and  also  from  the  extension  of  the  infection 
through  the  walls  of  the  tubes  to  its  peritoneal  covering, 
many  adhesions  are  formed  between  the  infected  tube  and 
the  other  pelvic  organs.  These  adhesions  vary  greatly  both 
in  quantity  and  density.  Some  are  very  easily  broken  up, 
while  others  are  extremely  firm  and  hard.     They  fix  the 


SALPINGITIS  195 

infected  tubes  and  ovaries  in  definite  positions  and  inter- 
fere with  their  expansion  during  the  congestion  associated 
with  menstruation.  They  are  in  this  way  responsible  for 
a  large  part  of  the  dysmenorrhea  that  accompanies 
salpingitis. 

Symptoms.  —  Pain  in  salpingitis  is  extremely  variable 
both  in  duration  and  severity.  The  character  of  the  pain 
present  has  no  definite  relation  to  the  extent  of  the  lesion. 


Fig.  104.  —  Hydrosalpinx. 

Some  of  the  milder  cases  give  rise  to  a  great  deal  of 
severe,  sharp  pain,  while  some  of  the  graver  cases  give 
rise  to  comparatively  little  pain.  Pain  is  almost  invariably 
increased  when  the  patient  is  in  the  erect  position,  and  is 
nearly  always  very  much  decreased  if  the  patient  remains 
quiet  in  the  recumbent  posture. 

During  menstruation  pain  is  increased.  The  increase  of 
pain  begins  a  few  days  before  the  flow  appears  and  con- 
tinues throughout  the  flow,  but  is  usually  lessened  some- 
what in  degree  after  the  flow  is  thoroughly  established. 
Usually  the  menstrual  flow  is  increased  both  in  frequency 


196 


DISEASES    OF    THE    FALLOPIAN    TUBES 


and  duration.  The  first  menstrual  flow  that  comes  on  after 
the  tubes  have  become  infected  is  very  commonly  char- 
acterized by  an  unusual  amount  of  pain,  an  unusually  free 
flow  of  blood  and  the  passing  of  clots.  Sometimes  these 
symptoms  are  so  marked  that  they  are  mistaken  for  the 
symptoms  of  a  miscarriage.  When  an  infection  starting 
in  the  tube  involves  the  ovaries  and  partially  or  completely 
destroys  them,  the  result  may  be  a  decrease  or  absence  of 
the  menstrual  flow. 


Fig.  105.  —  Hydrosalpinx.  (Photomicrograph.)  Only  a  small  segment  of 
the  circumference  of  the  tube  can- be  shown.  The  fragment  of  one  fold  of  mucous 
membrane  is  attached. 

There  is  usually  present  a  leucorrheal  discharge  due  to 
the  associated  infection  of  the  endometrium. 

In  the  earlier  stages  of  infection  the  pulse  and  tempera- 
ture are  usually  both  increased,  but  the  temperature  as  a 
rule  does  not  run  high  and  the  rise  continues  only  a  few 
days.  The  rise  of  temperature  is  most  marked  in  strepto- 
coccus infections. 

Diagnosis.  —  The  diagnosis  is  made  from  the  clinical  his- 
tory and  results  of  physical  examination.  Where  the  strep- 
tococcus is  the  infecting  organism,  there  is  usually  a 
history  of  labor  or  miscarriage  which  is  followed  by  a  rise 
of  temperature  and  pelvic  pain.  Where  the  infecting  organ- 
ism is  the  gonococcus,  there  will  be  a  history  of  frequent 


SALPINGITIS 


197 


and  burning  micturition  and  a  purulent  vaginal  discharge 
that  had  been  present  at  some  time  previous  to  the  be- 
ginning of  the  symptoms  that  are  associated  with  the 
salpingitis. 

The  physical  signs  vary  with  the  gross  pathological 
conditions.  In  the  catarrhal  form  frequently  very  little 
can  be  made  out  except  that  the  tubes  are  tender  on  palpa- 
tion.   When  a  purulent  salpingitis  is  present,  there  is  such 


Fig.  106.  —  Tubo-ovarian  Abscess. 

a  mass  of  adhesions  about  the  tube  that,  unless  it  is  un- 
usually distended,  no  signs  of  fluctuation  can  be  made  out; 
but  elongated  firm  masses  that  are  fixed  in  their  position 
on  both  sides  of  the  uterus  can  be  felt.  These  masses  are 
tender  on  pressure.  In  the  interstitial  form  the  tube  forms 
a  hard  adherent  mass  on  either  side  of  the  uterus.  There 
is  nothing  very  characteristic  of  hydrosalpinx.  It  is  usually 
not  bound  down  so  firmly  by  adhesions  as  those  in  which 
the  tube  has  been  more  severely  infected.    When  movable 


198 


DISEASES    OF    THE    FALLOPIAN    TUBES 


it  may  be  mistaken  for  a  small  ovarian  cyst.  A  tubo- 
ovarian  abscess  can  sometimes  be  distinguished  by  its 
definite  rounded  outlines. 
Prognosis.  —  Many  cases  of  salpingitis  recover  spontane- 
ously. Many  recover  under  palli- 
ative treatment.  In  those  cases 
where  there  is  a  formation  of  pus, 
the  tendency  is  to  have  recurring 
attacks  of  pain  and  discomfort 
ending  in  chronic  invalidism. 
The  actual  danger  to  life  from 
salpingitis  is  not  very  great. 
Occasionally  a  pyosalpinx  will 
rupture,  causing  a  general  peri- 
tonitis and  resulting  in  the  death 
of  the  patient,  but  excepting  the 
puerperal  infections,  this  acci- 
dent is  extremely  rare. 

Treatment.  —  During  the  acute 
stage  the  patient  should  be  kept 
in  bed.  Hot  vaginal  douches  are 
useful.  To  obtain  any  satisfac- 
tory results  the  quantity  of  water 
used  should  be  large  and  the  tem- 

Fig.  107. -Posterior  Vagi-  Perature  of  the  water  as  high  as 
nal  Section.    First  step.    The  can   be   borne   with   comfort   by 

line  of  incision  is  indicated.  the  patient      The  d(mclies  should 

be  given  with  the  patient  in  the  recumbent  position  with 
the  hips  elevated.  Glycerin  tampons  placed  in  the  vagina 
at  night  and  removed  each  morning  relieve  the  pain  by 
reducing  the  pelvic  congestion  and  promote  drainage  from 
the  uterus.  The  bowels  should  be  kept  active  by  the  use  of 
salines.  The  most  efficient  of  the  salines  for  this  purpose 
is  the  sulphate  of  magnesium.     It  is  given  preferably  in 


SALPINGITIS 


199 


dram  doses  sufficiently  often  to  keep  the  bowels  freely  open. 
It  assists  very  materially  in  relieving  the  pain.  Quite 
a  large  per  cent  of  patients  suffering  from  tubal  infections, 
if  seen  early  and  treated  persistently,  will  be  permanently 
relieved  of  their  symptoms. 


Fig.  108.  —  Posterior  Vaginal  Section.  Second  step.  A  speculum  has  been 
inserted  into  the  incision  and  the  abscess  wall  exposed. 

In  the  cases  where  there  has  been  a  virulent  infection,  and 
in  the  cases  where  the  infection  has  been  less  virulent,  but 
where  it  is  seen  late,  it  is  usually  necessary  to  resort  to 
some  operative  procedure  to  relieve  the  patient.  The  oper- 
ations are  done  either  by  the  vaginal  or  the  abdominal 
route,  according  to  the  condition  present. 


200 


DISEASES    OF    THE    FALLOPIAN    TUBES 


When  a  large  quantity  of  pus  is  collected,  especially 
when  due  to  a  streptococcus  infection,  it  is  much  safer  to 
drain  the  pus  cavities  through  the  posterior  vaginal  wall 
than  it  is  to  open  the  abdomen.  A  speculum  is  inserted  into 
the  vagina  and  the  perineum  retracted.  The  posterior  lip 
of  the  cervix  is  caught  with  bullet  forceps  and  drawn  up- 
ward. A  long  incision  is  made  in  the  median  line  of  the 
posterior  vaginal  wall  beginning  immediately  behind  the 
cervix  and  carried  downward  and  forward  for  at  least  two 
inches  (Fig.  107).    This  first  incision  goes  only  through  the 


Fig.  109.  —  Removal  of  Infected  Tube. 

vaginal  wall.  The  rectum  can  be  avoided  when  extending 
the  incision  downward  by  pulling  the  vaginal  wall  forward. 
From  this  point  by  blunt  dissection  the  pus  sac  is  exposed. 
A  long  retractor  can  now  be  inserted  directly  into  the  wound 
in  the  posterior  vaginal  wall  and  the  pus  sac  can  be  opened 
with  a  knife  directly  under  the  eye  of  the  operator  (Fig. 
108).  The  opening  in  the  sac  is  stretched  by  inserting  a 
pair  of  heavy  closed  forceps  into  the  incision  and  then  with- 
drawing them  after  they  are  opened.  The  pus  is  allowed 
to  drain  out,  but  the  cavity  is  not  irrigated.  A  piece  of 
gauze  a  yard  wide  and  long  enough  to  fill  up  the  cavity 
loosely  is  inserted  as  a  drain. 


SALPINGITIS 


201 


The  patient  is  placed  in  a  sitting  posture  immediately 
after  the  operation,  either  in  bed  or  in  a  chair.  At  the  end 
of  forty-eight  hours  a  few  inches  of  the  gauze  drain  is 
pulled  down  and  cut  off.  Thereafter  a  short  section  of  the 
drain  is  removed  every  forty-eight  hours  until  the  whole 
is  removed  on  the  eighth  day.  The  two  points  of  particular 
importance  in  this  operation  are  the  large  opening  in  the 
posterior  vaginal  wall  and  the  large  drain.     The  cases, 


Fig.  110.  —  Removal  of  Infected  Tube  and  Ovary. 


which  are  not  permanently  relieved  by  posterior  vaginal 
drainage,  are  in  a  very  much  better  condition  for  a  radical 
abdominal  operation  than  they  would  have  been  without 
the  drainage. 

When  operating  through  the  abdominal  wall  for  salpin- 
gitis the  patient  is  put  in  the  Trendelenburg  position.  The 
abdomen  is  opened  near  the  median  line  between  the  sym- 
physis and  umbilicus.  The  intestines  are  packed  away  from 
the  field  of  operation  by  gauze  pads.  This  packing  off  of 
the  intestines  serves  two  purposes:  first,  it  protects  the 


202  DISEASES    OF    THE    FALLOPIAN    TUBES 

contents  of  the  abdomen  from  infection;  second,  it  keeps 
the  intestines  from  being  exposed  to  the  atmosphere. 

In  the  cases  of  catarrhal  salpingitis  there  are  usually  few 
or  no  adhesions  and  no  involvement  of  the  ovaries,  so  that 
in  these  cases  it  is  necessary  to  remove  only  the  tubes.  The 
mesosalpinx  and  the  uterine  end  of  the  tube  are  clamped  and 
the  tube  cut  away.  The  mesosalpinx  including  the  severed 
end  of  the  tube  are  tied  off  in  sections.  If  the  inflammation 
is  due  to  any  micro-organism  except  the  gonococcus  it  may 
be  necessary  to  remove  only  one  tube,  but  if  it  is  due  to 
a  gonococcus  infection  both  tubes  should  be  removed. 

In  the  cases  of  purulent  salpingitis,  pyosalpinx,  or  inter- 
stitial salpingitis,  after  the  abdomen  is  opened  and  the  in- 
testines packed  off,  it  is  necessary  to  break  up  the  adhesions 
that  bind  the  tubes  and  ovaries  to  the  pelvic  walls  and 
pelvic  viscera.  This  is  best  done  by  inserting  the  finger,  with 
the  palm  side  forward  behind  the  body  of  the  uterus.  After 
freeing  the  posterior  uterine  wall  the  lines  of  cleavage  ordi- 
narily can  be  followed  to  both  sides,  freeing  the  tubes  and 
ovaries  from  their  posterior  adhesions.  No  attempt  should 
be  made  to  bring  up  either  tube  until  the  adhesions  on  both 
sides  are  broken  up.  In  a  great  many  cases  both  ovaries 
are  so  badly  disorganized  that  it  is  necessary  to  remove 
them  together  with  the  tubes. 

In  all  cases,  and  especially  in  women  under  thirty-five, 
where  it  is  possible,  at  least  a  portion  of  one  or  both 
ovaries  should  be  allowed  to  remain.  When  a  tube  and 
ovary  together  are  to  be  removed  the  broad  ligament  is 
clamped  just  beyond  the  end  of  the  tube,  and  the  second 
clamp  is  put  on  the  broad  ligament  including  the  tube 
close  to  the  uterus.  These  two  clamps  control  the  blood 
supply.  By  cutting  out  a  V-shaped  piece  of  the  ligament 
between  the  clamps,  the  tube  and  ovary  are  removed.  The 
clamps  are  replaced  by  ligatures.     By  tying  the  ends  of 


SALPINGITIS 


203 


these  ligatures  together  the  notch  in  the  broad  ligament 
is  closed. 

In  those  cases  in  which  the  ovaries  are  destroyed  and 
in  which  there  is  an  endometritis  and  a  metritis  with  an  en- 
largement of  the  uterus  associated  with  the  tubal  infection, 
the  best  results  are  obtained  by  supravaginal  hysterectomy. 
After  separating  the  adhesions  in  most  instances  the  oper- 
ation is  identical  with  that  of  supravaginal  hysterectomy 


Fig.  111.  —  Posterior  Vaginal  Drain.    The  method  of  introducing  a  gauze 
drain  from  the  abdominal  wound  out  through  the  posterior  vaginal  wall  is  shown. 

for  fibroids.  In  some  instances  it  is  not  possible  to  break 
up  the  adhesions  on  one  side  from  above.  When  that  is 
the  case  the  uterine  and  ovarian  arteries  on  the  side  where 
the  adhesions  can  be  separated  are  clamped  and  cut  through. 
An  incision  is  made  through  the  cervix,  the  uterine  artery 
on  the  side  of  the  dense  adhesions  is  clamped,  and  the 
adhesions  are  separated  from  below  upward.  In  rare  in- 
stances it  is  necessary  to  split  the  uterus  from  the  fundus 
down  to  the  cervix,  cut  through  the  cervix  on  either  side, 
and  secure  the  uterine  arteries.     Then  separate  the  adhe- 


204  DISEASES    OF    THE    FALLOPIAN    TUBES 

sions  from  below  upward  on  both  sides.  Before  the  stump 
of  the  cervix  is  covered  with  the  peritoneal  flap  the  cervical 
mucous  membrane  should  be  burned  out  with  a  cautery. 

The  pus  due  to  a  long-standing  gonorrheal  infection  is 
nearly  always  sterile.  Pus  due  to  a  streptococcus  infection 
is  usually  not  sterile.  In  any  case  where  there  is  any  ques- 
tion as  to  the  sterility  of  the  pus  present,  a  drain  should 
be  put  in.  The  most  favorable  position  for  a  drain  is 
through  the  posterior  vaginal  wall.  An  assistant  intro- 
duces a  long  curved  forceps  through  the  vagina  and  pushes 
up  the  posterior  fornix  as  far  as  possible.  An  incision  is 
made  down  on  the  point  of  the  forceps  and  the  forceps  are 
pushed  into  the  cavity  of  the  pelvis.  The  opening  in  the 
posterior  vaginal  wall  can  be  enlarged  by  forcibly  opening 
the  forceps  while  they  are  in  this  position.  A  large  gauze 
drain  is  introduced  through  the  abdominal  wound,  grasped 
by  the  forceps,  and  drawn  down  until  the  end  projects  well 
into  the  vagina  (Fig.  111).  The  lower  portion  of  this  drain 
which  extends  through  the  vaginal  wound  should  be  covered 
by  rubber  protective  tissue.  Enough  of  the  drain  is  folded 
into  the  pelvic  cavity  to  fill  it  loosely  and  the  remainder  is 
cut  off.  The  sigmoid  and  omentum  are  drawn  over  the 
drain.    The  abdominal  wound  is  completely  closed. 

All  patients  operated  upon  for  salpingitis  should  be  put 
in  the  upright  position  immediately  after  operation  whether 
they  are  drained  or  not. 

TUBERCULOUS   SALPINGITIS 

The  bacillus  tuberculosis  invades  the  tubes  relatively 
frequently.  The  infection  reaches  the  tubes  by  direct 
continuity  of  tissue  either  from  the  uterus  or  from  the 
peritoneum.  It  may  be  conveyed  there  by  the  blood  current 
from  distant  foci,  or  may  be  carried  from  other  points  in 


TUBERCULOUS    SALPINGITIS  205 

the  genital  tract  by  the  lymphatics.  The  infection  may 
go  directly  to  the  tubes  from  below  without  infecting  the 
vulva,  vagina,  or  uterus.  It  may  occur  at  any  age,  but  the 
majority  of  cases  are  seen  before  the  patient  is  thirty  years 
of  age.  Nearly  all  cases  of  salpingitis  occurring  in  virgins 
are  tuberculous. 

Pathology.  —  There  is  a  very  great  variety  in  the  gross 
appearance  of  tubes  affected  with  tuberculosis.     The  tube 


Fig.  112.  —  Tuberculous  Salpingitis. 

is  sometimes  so  slightly  enlarged  or  so  closely  resembles 
the  ordinary  catarrhal  salpingitis,  that  tuberculosis  is  not 
suspected.  There  is  a  tendency  to  the  formation  of  irregu- 
larly sized  enlargements  in  the  tube.  The  end  of  the  tube 
in  long-standing  cases  is  closed  and  the  cavity  may  be  dis- 
tended with  serous  or  bloody  fluid  or  pus.  In  some  of  the 
mixed  infections  it  is  not  possible  to  recognize  the  tubercu- 
lous element  by  the  gross  appearance.  Usually  tubercles 
can  be  seen  studding  the  outer  side  of  the  tube.  More  or 
less  tuberculous  peritonitis  as  a  rule  is  associated  with  the 


206 


DISEASES    OF    THE    FALLOPIAN    TUBES 


tubal  infection.  This  peritonitis  may  be  limited  to  an  area 
very  close  to  the  tube,  or  it  may  spread  to  a  great  extent 
throughout  the  abdominal  peritoneum.  There  may  be  an 
aggregation  of  tubercles  which  undergo  caseous  degenera- 
tion. In  some  instances  the  lumen  of  the  tube  will  be  dis- 
tended with  caseous  material.    Microscopical  examination 


b 


Fig.  113.  —  Tuberculous  Salpingitis.  (Photomicrograph.)  A,  giant  cells; 
B,  caseous  area;   C,  area  of  small  round-cell  infiltration. 

shows  giant  cells  and  small  caseous  areas  in  the  mucosa  of 
the  tube.  There  is  much  small  round-cell  infiltration  beyond 
these  caseous  areas  (Fig.  113).  The  wall  of  the  tube  usually 
shows  only  round-cell  infiltration. 

Symptoms.  —  There  are  no  distinguishing  symptoms  of 
tuberculous  infection  of  the  tube.  In  cases  of  long-standing 
salpingitis  in  virgins,  or  when  there  are  tubercular  infec- 
tions present,  tuberculosis  may  be  suspected. 


TUMORS    OF    THE    FALLOPIAN    TUBES  207 

Diagnosis.  —  Usually  the  diagnosis  of  tuberculosis  salpin- 
gitis is  not  made  until  after  the  abdomen  is  opened.  In 
many  instances  it  is  not  made  until  sections  of  the  tubes 
are  examined  microscopically. 

Prognosis.  —  The  prognosis  depends  very  largely  upon 
whether  the  tuberculous  infection  is  distributed  to  other 
portions  of  the  body.  Where  the  infection  is  limited  to 
the  tubes  and  to  the  peritoneum  immediately  surrounding 
them  and  the  uterus,  the  prognosis  is  good. 

Treatment.  —  The  tubes  should  be  removed  by  abdominal 
section.  If  the  uterus  is  involved,  hysterectomy  should 
be  done.  The  involvement  of  the  peritoneum  is  no  contra- 
indication for  operation. 

TUMORS    OF    THE    FALLOPIAN    TUBES 

Fibromyoma.  —  Fibromyomata  developing  from  the  mus- 
cular layer  of  the  Fallopian  tube  occasionally  occur.  They 
are  usually  of  very  small  size  and  have  little  clinical 
significance. 

Papilloma.  —  Papillomata  of  the  tube  sometimes  grow  to 
the  size  of  an  orange.  They  have  a  tendency  to  take  on 
malignant  changes.  When  the  end  of  the  tube  remains  open 
the  secretion  from  the  papillomata  accumulates  in  the  peri- 
toneal cavity  producing  ascites. 

Carcinoma.  —  A  carcinoma  in  very  rare  instances  devel- 
ops from  the  epithelium  lining  the  mucous  membrane  of 
the  tube.  Secondary  carcinoma  may  be  an  extension  from 
the  ovary  or  some  of  the  other  adjacent  viscera.  The  tube 
is  very  rarely  involved  in  carcinoma  of  the  uterus. 

Sarcoma.  —  Sarcoma  of  the  tube  is  rarely  met  with. 


208  PELVIC    CELLULITIS 


PELVIC    CELLULITIS 

Pelvic  cellulitis  or  parametritis  is  an  infection  of  the 
loose  connective  tissue  lying  between  the  peritoneal  folds 
that  make  up  the  ligaments  of  the  uterus.  The  infecting 
micro-organism  is  nearly  always  the  streptococcus.  It 
usually  follows  a  labor  or  a  miscarriage.  The  organisms 
enter  the  tissues  through  the  placental  site  or  through 
abrasions  in  the  cervix,  vagina,  or  perineum.  They  reach 
the  deeper  structures  in  the  pelvis  by  way  of  the  lymph 
vessels  and  veins.  The  infection  tends  to  localize  itself 
in  one  place.  This  is  most  frequently  in  the  base  of  the 
broad  ligament.  Sometimes  the  principal  point  of  infection 
will  be  in  the  utero-sacral  or  utero-vesical  ligaments.  There 
is  always  a  certain  amount  of  associated  pelvic  peritonitis. 
There  is  a  very  great  amount  of  exudate  which  forms  a 
hard  resistant  mass  in  the  pelvis.  This  may  undergo  reso- 
lution or  may  break  down  with  the  formation  of  pus.  These 
accumulations  of  pus  have  a  tendency  to  follow  the  lines 
of  the  loose  connective  tissue  and  ultimately  to  break  into 
the  rectum,  vagina,  bladder,  or  through  the  abdominal 
wall.  After  the  rupture  the  pus  cavity  may  drain  com- 
pletely and  heal  up.  In  other  instances  there  may  be  a 
fistulous  tract  formed  that  will  remain  patulous  for  a  long 
time. 

Symptoms.  —  The  first  symptom  observed  ordinarily  is 
a  severe  chill  followed  by  a  rise  of  temperature.  As  soon 
as  there  is  much  tension  developed  in  the  pelvis,  pain  is 
produced.  This  pain  is  often  quite  severe  in  character. 
If  the  exudate  is  in  such  a  position  as  to  cause  direct  pres- 
sure upon  the  rectum  or  bladder,  there  will  be  painful 
defecation  and  pain  on  urination. 

Diagnosis.  —  On  physical  examination  a  hard  mass  is  felt 


PELVIC    CELLULITIS  209 

usually  on  one  side  of  the  uterus.  In  exceptional  cases 
both  sides  may  be  involved.  The  uterus  is  firmly  fixed  in 
its  position.  Even  when  there  are  considerable  quantities 
of  pus  present  the  amount  of  exudate,  surrounding  the  fluid, 
is  so  great  that  fluctuation  as  a  rule  cannot  be  detected. 
These  physical  signs  taken  in  connection  with  the  sudden 
onset  during  the  puerperium  is  usually  sufficient  for  making 
a  diagnosis. 

Treatment.  —  In  the  early  stage  of  the  disease  the  patient 
should  be  kept  in  bed.  Sulphate  of  magnesia  should  be 
given  in  sufficient  quantities  to  keep  the  bowels  loose.  Hot 
applications  over  the  lower  portion  of  the  abdomen  and 
hot  vaginal  douches  give  some  relief.  When  the  pain  is 
excessive,  morphia  should  be  given  in  sufficient  doses  to 
mitigate  it.  When  there  is  a  formation  of  pus,  the  ma- 
jority are  best  drained  through  an  incision  in  the  median 
line  of  the  posterior  vaginal  wall.  In  exceptional  cases  it 
is  necessary  to  make  an  opening  between  the  uterus  and 
the  bladder  to  reach  the  pus.  Occasionally  the  abscess 
points  in  the  neighborhood  of  Poupart's  ligament  and  is 
best  opened  through  the  abdominal  wall.  Wherever  the 
opening  is  made  it  should  be  wide  and  the  pus  cavity  should 
be  packed  loosely  with  sterile  gauze.  This  gauze  is  gradu- 
ally removed.  The  incision  must  be  kept  open  until  there 
is  healing  from  the  bottom  of  the  abscess  cavity. 


CHAPTER   XVI 

EXTRAUTERINE    PREGNANCY 

"  Ectopic  gestation  "  and  "  tubal  pregnancy  "  are  used 
synonymously  with  extrauterine  pregnancy.  Extrauterine 
pregnancy  means,  as  its  name  indicates,  the  development 
of  an  impregnated  ovum  anywhere  outside  of  the  uterus. 
Extrauterine  pregnancies  occur  much  more  frequently  than 
is  generally  believed.  Very  few  of  them  give  rise  to  the 
train  of  severe  symptoms  that  is  generally  recognized 
as  indicating  a  ruptured  tubal  pregnancy.  There  are  un- 
doubtedly large  numbers  of  cases  that  recover  without 
ever  being  discovered.  A  uterine  and  a  tubal  pregnancy 
occasionally  occur  together,  as  do  also  multiple  tubal 
pregnancies. 

Etiology.  —  Extrauterine  pregnancy  occurs  most  fre- 
quently in  patients  who  have  a  relative  sterility.  The  direct 
cause  in  most  instances  is  probably  some  obstruction  of  the 
calibre  of  the  tube  that  is  due  either  to  a  congenital  defect 
or  that  has  resulted  from  an  infection.  In  most  instances 
it  is  impossible  to  determine  the  definite  cause  which  pre- 
vented the  ovum  from  passing  through  the  tube  to  the 
uterus. 

Pathology.  —  The  uterus  is  usually  slightly  enlarged,  but 
it  never  approaches  the  size  it  would  be  at  the  correspond- 
ing period  of  uterine  pregnancy.  On  bimanual  examination 
the  uterus  never  feels  cystic  as  it  does  in  a  uterine  preg- 
nancy. The  endometrium  is  somewhat  thickened  and  has 
the  general  characteristics  of  a  premenstrual  endometrium, 

210 


PATHOLOGY 


211 


the  only  difference  being  that  the  changes  which  occur  in 
the  endometrium  just  before  menstruation  are  exaggerated 
in  extrauterine  pregnancy.  The  glands  are  more  widely 
distended  and  the  stroma  cells  approach  more  nearly  the 
true  decidual  type  than  they  do  in  the  premenstrual  endo- 
metrium. In  the  tube  the  muscular  fibers  are  increased  in 
size  and  the  calibre  of  the  blood-vessels  is  enormously  in- 
creased. Chorionic  villi  are  found  in  the  lumen  of  the  tube 
and  decidual  cells  in  the  tube  wall. 


Fig.    114.  —  Diagram    Showing    Various    Locations    of  Extrauterine 
Pregnancy  in  the  Tube. 


Practically  all  extrauterine  pregnancies  are  originally 
tubal.  Very  rarely  an  ovarian  pregnancy  occurs.  The 
ovum  starts  to  develop  either  in  the  isthmus  or  the  ampulla 
of  the  tube.  As  the  ovum  develops,  the  tension  in  the  tube 
is  increased  and  the  chorionic  villi  pushing  into  the  wall 
of  the  tube  from  the  ovum  erode  and  weaken  it.  These  two 
processes,  the  increasing  tension  and  the  erosion,  finally 
cause  the  tube  to  rupture.  The  direction  of  the  rupture 
is  fixed  by  the  point  at  which  the  greatest  amount  of  erosion 
has  taken  place. 

If  the  ovum  has  lodged  in  the  isthmus  of  the  tube,  the 


212         EXTRAUTERINE  PREGNANCY 

rupture  may  take  place  either  upward  into  the  peritoneal 
cavity  or  downward  into  the  broad  ligament.  If  the  amniotic 
sac  is  broken  at  the  time  of  a  rupture  downward,  the  death 
of  the  fetus  follows  and  the  fetus  can  seldom  be  found. 
The  only  result  of  the  rupture  is  the  formation  of  a  hema- 


Fig.  115.  —  Extrauterine  Pregnancy.  Ruptured  tube,  fetus,  and  early 
placenta. 

toma  in  the  broad  ligament.  If  the  amniotic  sac  is  not 
broken  the  fetus  may  continue  to  develop  between  the 
layers  of  the  broad  ligament. 

When  the  rupture  takes  place  into  the  peritoneal  cavity 
there  is,  exceptionally,  an  immediate  profuse  hemorrhage 
into  the  abdomen.  Usually,  however,  the  hemorrhage  is 
only  moderate  in  amount,  and  the  irritation  of  the  peri- 
toneum by  the  free  blood  causes  sufficient  plastic  exudate 


PATHOLOGY  213 

to  partially  or  completely  encapsulate  it.  Secondary  rup- 
tures usually  occur  and  the  process  of  encapsulation  is 
repeated. 

What  is  known  as  a  tubal  abortion  is  the  partial  or  com- 
plete escape  of  the  ovum  from  the  fimbriated  extremity  of 
the  tube.  When  an  unbroken  amniotic  sac  escapes  into 
the  abdomen,  either  through  a  rupture  in  the  tube  or  from 
the  fimbriated  extremity,  the  fetus  may  continue  to  develop 
as  an  abdominal  pregnancy.    An  abdominal  pregnancy  may 


Fig.  116.  —  Tubal  Abortion. 

go  to  full  term.  The  placenta  attaches  itself  to  the  broad 
ligament,  or  to  the  walls  of  the  pelvis,  or  partially  to  any 
of  the  pelvic  viscera. 

When  the  death  of  the  fetus  occurs  during  an  early  period 
of  its  development  it  is  usually  promptly  absorbed  along 
with  the  blood  that  is  in  the  peritoneal  cavity.  If  the  ovum 
has  continued  to  develop  for  several  months  before  the 
death  of  the  fetus  occurs,  several  processes  may  result.  The 
fetus  may  become  mummified  or  lime  salts  may  become 
deposited  in  it.  This  latter  is  the  so-called  lithopedian. 
Either  of  these  two  forms  may  remain  in  the  abdomen  for 
years  without  giving  rise  to  very  much  trouble.     In  other 


214         EXTRAUTERINE  PREGNANCY 

instances  infection  takes  place  resulting  in  an  abscess.  The 
infection  may  occur  very  soon  after  the  death  of  the  fetus 
or  it  may  be  delayed  for  months  or  years.  The  abscess  may 
rupture  either  through  the  abdominal  wall  or  into  the  in- 
testine with  the  extrusion  of  fetal  remains  through  the 
opening. 

When  the  gestation  extends  to  full  term  there  may  be  a 
spurious  labor,  after  which  the  death  of  the  fetus  usually 
occurs.  When  the  fetus  dies,  the  circulation  in  the  placenta 
ceases. 

Symptoms.  —  The  symptoms  produced  by  an  extrauterine 
pregnancy  up  to  the  time  of  rupture  or  tubal  abortion  differ 
very  little  from  those  associated  with  normal  pregnancy. 
The  most  common  time  for  the  rupture  to  take  place  is 
during  the  first  week  of  the  second  month  of  the  pregnancy. 
In  a  few  cases  the  rupture  occurs  before  the  first  month  of 
pregnancy  is  complete,  and  some  ruptures  are  delayed  until 
after  the  second  month.  The  immediate  symptoms  pro- 
duced by  the  rupture  are  modified  by  the  direction  of  the 
rupture  and  the  amount  of  blood  poured  out. 

When  the  rupture  takes  place  into  the  peritoneal  cavity 
and  when  there  is  an  immediate  loss  of  a  large  quantity 
of  blood  there  is  at  once  a  sharp,  severe  pain  and  acute 
anemia;  the  heart  is  rapid  and  weak;  the  respiration  is 
sighing ;  the  skin  is  cold  and  covered  with  beads  of  perspira- 
tion; and  the  patient  frequently  loses  consciousness.  Ex- 
cepting the  pain,  these  symptoms  are  the  same  as  those  of 
any  other  sudden  large  internal  hemorrhage.  Fortunately 
comparatively  few  cases  have  these  severe  hemorrhages  at 
the  first  rupture. 

In  the  vast  majority  of  cases  the  primary  rupture  is 
either  a  minor  rupture  into  the  peritoneal  cavity  with  slight 
hemorrhage  or  a  rupture  into  the  broad  ligament,  or  there 
is  an  incomplete  tubal  abortion.     The  symptoms  in  these 


DIAGNOSIS  215 

cases  are  frequently  so  slight  that  the  cause  of  them  is  en- 
tirely overlooked.  Usually  there  is  at  first  a  very  con- 
siderable amount  of  pain,  a  very  moderate  amount  of  shock 
or  none,  and  blood  begins  to  dribble  from  the  uterus.  The 
pain  may  pass  off  entirely  for  some  days  and  then  recur 
from  time  to  time  as  fresh  hemorrhages  take  place.  A 
small  continuous  flow  of  blood  from  the  uterus  is  very 
persistent.  The  amount  of  blood  coming  away  is  never  very 
large,  but  the  continuity  of  the  flow  is  one  of  the  most  char- 
acteristic symptoms  of  extrauterine  pregnancy. 

Diagnosis.  —  The  most  important  thing  in  the  diagnosis 
of  extrauterine  pregnancy  is  the  menstrual  history.  It  is 
necessary  to  learn,  if  possible,  the  exact  dates  of  the  men- 
strual periods  for  the  two  or  three  periods  previous  to 
the  onset  of  the  symptoms.  Almost  invariably  it  will  be 
found  that  the  interval  between  two  of  these  periods  has 
been  longer  than  normal.  In  a  large  percentage  of  cases 
the  patient  will  have  gone  over  her  regular  time  only  a 
few  days.  This  history  of  the  missed  menstrual  period,  the 
recurrence  of  the  bleeding  associated  with  an  amount  of 
pain  greater  than  the  pain  ordinarily  experienced  with  men- 
struation, and  the  fact  that  the  dribble  of  blood  continues 
far  beyond  the  time  of  an  ordinary  menstruation  are  very 
significant  of  extrauterine  pregnancy. 

Usually  on  bimanual  examination  the  uterus  is  found 
slightly  enlarged  and  firm,  and  a  boggy  mass  can  be  pal- 
pated on  one  side  of  the  uterus.  When  the  hemorrhage  is 
directed  into  the  broad  ligament  this  mass  has  a  clearly 
defined  upper  border.  The  size  of  the  mass  may  vary  any- 
where from  a  slightly  enlarged  tube  to  a  tumor  that  fills 
up  the  pelvis  and  the  lower  abdomen  as  high  as  the  um- 
bilicus. On  vaginal  examination  there  is  extreme  tender- 
ness over  the  mass.  This  tenderness  to  pressure  is  very 
much  more  marked  than  it  is  in  any  other  pelvic  condition. 


216         EXTEAUTEKIKE  PKEGNANCY 

In  the  exceptional  cases  where  there  is  a  sudden  large 
hemorrhage  into  the  abdomen  the  diagnosis  can  usually  be 
made  on  the  history  of  a  missed  menstrual  period  and  the 
indications  of  internal  hemorrhage.  In  some  of  these  cases 
if  examined  immediately  after  the  rupture  has  taken  place 
and  before  the  blood  has  had  time  to  coagulate,  nothing  ab- 
normal can  be  felt.  In  the  majority  of  them  an  indefinite 
boggy  mass  can  be  felt  in  the  pelvis. 

Treatment.  —  The  treatment  of  rupture  of  an  extra- 
uterine pregnancy  with  severe  hemorrhage  into  the  ab- 
dominal cavity  is  essentially  the  same  as  that  of  any  other 
severe  internal  hemorrhage.  The  indication  for  the  treat- 
ment is  the  hemorrhage.  The  hemorrhage  can  be  controlled 
only  by  opening  the  abdomen  and  tying  off  the  bleeding 
vessels.  Ordinarily  the  tube  is  removed.  When  the  indi- 
cations are  that  the  hemorrhage  is  progressing,  the  opera- 
tion should  be  done  at  the  earliest  possible  moment.  In 
those  cases  in  which  the  indications  are  that  the  hemorrhage 
has  already  ceased  it  is  best  to  wait  until  the  patient  has 
somewhat  recovered  from  the  shock  of  the  rupture  before 
proceeding  with  the  operation.  This  differentiation  as  to 
whether  the  hemorrhage  has  ceased  or  not  is  frequently 
very  difficult  to  make  and,  in  cases  of  doubt,  it  is  best 
to  proceed  with  the  operation. 

In  the  vast  majority  of  cases  the  condition  is  not  an 
emergency  one,  and  while  it  is  essential  that  these  patients 
should  have  the  source  of  danger  removed,  both  the  local 
and  the  general  condition  of  the  patient  justify  taking 
sufficient  time  to  get  the  patient  into  the  best  surroundings 
for  safe  operation.  There  is  usually  no  difficulty  in  deter- 
mining beforehand  which  tube  is  ruptured,  and  in  operating, 
the  ruptured  tube  should  be  brought  up  and  tied  off  im- 
mediately. After  the  source  of  hemorrhage  has  been 
stopped  the  larger  blood  clots  should  be  removed  from 


TBEATMENT  217 

the  abdomen,  but  it  is  not  necessary  to  waste  time  and 
unnecessarily  expose  the  intestines  in  making  an  elaborate 
toilet  of  the  peritoneum.  A  moderate  amount  of  blood 
left  in  the  abdomen  causes  no  trouble.  The  abdomen  is 
closed  without  drainage. 

Large  pelvic  hematoceles,  and  especially  those  that  have 
become  infected,  should  be  opened  and  drained  through 
the  posterior  vaginal  wall.  When  the  drainage  operation  is 
undertaken,  preparation  should  always  be  made  for  doing 
an  abdominal  operation  if  it  should  become  necessary  to 
open  the  abdomen  to  control  the  hemorrhage. 

If  an  extrauterine  pregnancy  continues  to  develop  until 
after  the  formation  of  the  placenta,  as  long  as  the  fetus 
is  living  it  is  extremely  dangerous  to  attempt  its  removal. 
The  danger  consists  in  the  inability  in  many  cases  to  control 
the  hemorrhage  from  the  site  of  the  partially  or  completely 
separated  placenta.  When  the  placenta  is  adherent  only 
to  the  uterus  and  broad  ligaments,  the  blood  supply  to  it 
can  be  controlled;  but  if  it  is  adherent  to  the  intestines 
or  pelvic  wall,  it  is  impossible  to  control  the  blood  supply. 
The  most  satisfactory  way  to  deal  with  the  cases  in  which 
the  fetus  is  living  after  the  fourth  month  is  to  open  the 
amniotic  sac  in  the  least  vascular  portion,  remove  the  fetus, 
stitch  the  edges  of  the  wound  in  the  amniotic  sac  to  the 
edges  of  the  wound  in  the  abdominal  wall,  and  pack  the 
cavity  with  sterile  gauze. 

After  the  death  of  the  fetus  and  the  cessation  of  the  cir- 
culation in  the  placenta,  both  can  usually  be  removed  with 
comparative  ease  and  safety. 


CHAPTER   XVII 

DISEASES    OF    THE    OVARIES 

ANATOMY 

The  ovaries  are  two  almond-shaped  bodies  that  vary 
greatly  in  size.  In  young  women  they  are  about  one  inch 
and  a  quarter  long  by  three-quarters  of  an  inch  wide. 
Later  in  life  they  usually  decrease  in  size  and  become 
irregular  in  outline.  The  surface  of  the  ovary  is  yellowish 
white.  It  is  covered  by  a  layer  of  cells  that  are  the  con- 
tinuation of  the  endothelial  cells  of  the  posterior  layer 
of  the  broad  ligament.  These  cells  are,  however,  so  modi- 
fied in  their  appearance  as  not  to  be  recognizable  as  endo- 
thelial cells. 

The  outer  portion  or  cortex  of  the  ovary  is  made  up  of 
firm  connective  tissue  and  has  imbedded  in  it  many  imma- 
ture Graafian  follicles  (Fig.  117).  The  number  of  these 
Graafian  follicles  varies  with  the  age  of  the  woman.  In 
young  women  they  are  very  numerous.  Estimates  have 
been  made  varying  from  thirty  thousand  to  two  hundred 
thousand.  As  the  woman  advances  in  years  the  number  of 
Graafian  follicles  decreases  rapidly.  In  a  partially  de- 
veloped Graafian  follicle  the  epithelial  lining  and  the  group 
of  cells  called  the  discus  proligerus  containing  the  ovum 
is  clearly  seen.  A  corpus  luteum  develops  in  the  process 
of  repair  after  the  rupture  of  a  matured  Graafian  follicle 
(Fig.  118).  The  so-called  lutein  cells  present  all  the  char- 
acteristics of  new  connective  tissue  cells,  and  later  contract 

218 


ANATOMY 


219 


forming  a  mass  of  scar  tissue  called  a  corpus  albicans. 
The  central  portion  of  the  ovary  is  made  up  of  connective 
tissue  and  has  numerous  blood-vessels.  The  portion  of 
the  ovary  which  is  contiguous  to  the  broad  ligament  is 
called  the  hilum. 


Fig.  117.  —  Cortex  of  a  Normal  Ovary.  (Photomicrograph.)  Many  im- 
mature Graafian  follicles  are  seen  imbedded  in  dense  connective  tissue.  The  con- 
cave side  of  the  picture  is  a  segment  of  the  wall  of  a  Graafian  follicle  cyst. 

The  ovaries  are  situated  one  on  either  side  of  the  uterus 
just  below  the  Fallopian  tubes  and  posterior  to  the  broad 
ligaments.  The  ovary  is  kept  in  its  position  by  its  attach- 
ment to  the  broad  ligament  and  by  the  utero-ovarian  liga- 
ment. The  anterior  layer  of  the  broad  ligament  passes 
down  in  front  of  the  ovary.  The  posterior  layer  of  the 
broad  ligament  in  a  modified  form  spreads  out  over  the 
surface  of  the  ovary.    The  utero-ovarian  ligament  is  made 


220 


DISEASES    OF    THE    OVARIES 


up  of  muscular  and  fibrous  tissue  and  extends  between 
the  layers  of  the  broad  ligament  from  the  side  of  the  uterus 
just  below  the  Fallopian  tube  to  the  uterine  end  of  the 
ovary.  One  of  the  fimbriae  from  the  Fallopian  tube  is 
attached  to  the  ovary.  The  blood-vessels,  nerves,  and  lym- 
phatics enter  the  ovary  through  the  hilum. 


B 


Fig.  118.  —  Corpus  Luteum.     (Photomicrograph.)    A,  blood  clot;  B,  the  new 
connective  tissue  or  lutein  cells;  C,  ovarian  stroma. 


PERIOOPHORITIS 

In  perioophoritis  the  surface  of  the  ovary  becomes  in- 
fected from  an  infection  of  the  pelvic  peritoneum.  Ad- 
hesions are  formed  which  bind  the  ovary  down  to  a  fixed 
position,  and  these  adhesions  are  responsible  for  many 
of  the  changes  in  the  ovary  itself.  Under  the  conditions 
present  the  Graafian  follicles  are  not  able  to  develop  and 
rupture  in  the  normal  manner.    As  a  result,  numerous  small 


OOPHORITIS 


221 


cysts  form  in  the  ovary.  The  increased  pressure  causes 
an  atrophy  of  the  cortical  substance.  Many  of  the  so-called 
cystic  ovaries  develop  in  this  way. 

OOPHORITIS 

Infections  of  the  ovary  in  nearly  all  instances  are  asso- 
ciated with  tubal  infections  (Fig.  119) .  In  exceptional  cases 
the  ovary  becomes  infected  through  the  lymphatics  from 
some  other  source  than  the  tubes.     It  is  very  exceptional 


Fig.  119.  —  Infected  Ovary.     (Photomicrograph.)    The  stroma  of  the  ovary 
is  infiltrated  with  numerous  small  round  cells. 

for  the  ovary  to  be  infected  except  in  cases  of  mumps, 
without  other  pelvic  infections  that  entirely  mask  the 
ovarian  condition.  For  this  reason  acute  oophoritis  as  a 
disease  is  of  very  little  clinical  importance. 


222  DISEASES    OF    THE    OVARIES 

CYSTIC    OVARIES 

(Chronic  Oophoritis) 

The  condition  that  is  ordinarily  recognized  as  chronic 
oophritis  may  be  secondary  to  an  acute  infection,  or  it  may 
not  be  due  to  an  infection  at  all.  These  latter  cases  are  not 
true  inflammatory  conditions,  but  are  due  to  long-continued 
congestion  of  the  ovary  brought  about  by  adhesions,  by 
ovarian  displacements,  or  by  other  associated  lesions. 

Pathology.  —  The  ovary  is  usually  enlarged.  There  are 
numerous  Graafian  follicles  distended  with  a  clear  fluid. 
The  stroma  between  the  Graafian  follicles  is  thinned  out. 
The  number  of  normal  follicles  is  decreased.  The  blood- 
vessels in  the  deeper  portions  of  the  ovary  are  apparently 
increased  in  number,  congested,  and  the  walls  of  all  of 
them  are  very  much  thickened.  These  ovaries  are  known 
as  cystic  ovaries,  and  the  condition  is  spoken  of  as  cystic 
degeneration  of  the  ovaries. 

Symptoms.  —  The  symptoms  in  these  cases  are  quite  vari- 
able. There  is  usually  pain  referred  to  the  back  and  the 
iliac  regions.  This  pain  is  increased  when  the  patient  is 
much  on  her  feet.  There  is  usually  dysmenorrhea.  The 
pain  associated  with  the  menstrual  period  usually  begins 
several  days  before  the  period,  and  has  a  tendency  to  recur 
after  the  cessation  of  the  flow.  In  most  instances  there  is 
an  increased  menstrual  flow,  but  in  the  later  stages  of  the 
disease,  if  there  has  been  much  destruction  of  ovarian  tissue, 
the  menses  decrease  in  quantity. 

Diagnosis.  —  The  diagnosis  can  usually  be  made  by  find- 
ing the  enlarged  ovary  on  bimanual  examination.  In  many 
instances  it  is  excessively  tender  to  pressure.  Some  of 
these  cysts  rupture  spontaneously,  and  when  examinations 


HEMATOMA    OF    THE    OVARY  223 

of  the  patient  are  made  at  considerable  intervals  it  may  be 
found  that  the  size  of  the  ovary  has  changed  very  materially 
between  two  examinations. 

Treatment.  —  Both  local  and  constitutional  medical  treat- 
ment in  these  cases  are  generally  useless.  Eelief  is  to  be 
had  only  by  resorting  to  some  surgical  measure.  In  these 
cases  the  route  of  approach  is  usually  abdominal.  In  many 
instances  the  cysts  can  be  either  simply  punctured  or  enu- 
cleated. In  the  majority  of  cases  the  most  satisfactory 
procedure  is  a  resection  of  the  ovary.  A  wedge-shaped 
piece  including  the  diseased  portion  of  the  ovary  is  taken 
out,  leaving  behind  as  much  as  possible  of  the  normal 
ovarian  tissue.  The  wound  in  the  ovary  is  then  brought 
together  by  an  over-and-over  fine  catgut  suture.  There 
is  usually  no  hemorrhage  of  any  moment.  In  a  few  cases 
it  is  advisable  to  remove  the  ovary.  This  should  not  be 
done  so  long  as  there  is  any  ovarian  tissue  of  value  left. 


HEMATOMA   OF   THE    OVARY 

In  hematoma  of  the  ovary  there  is  a  collection  of  blood 
in  one  or  more  Graafian  follicles.  These  hematomata  vary 
in  size  from  small  accumulations  of  blood  to  as  much 
as  two  ounces.    The  smaller  ones  are  much  more  common. 

Symptoms.  —  The  symptoms  that  a  hematoma  of  the 
ovary  gives  rise  to  are  very  similar  to  those  found  associ- 
ated with  cystic  ovaries,  except  that  the  symptoms  due  to 
hematoma  are  usually  more  severe. 

Diagnosis.  —  The  diagnosis  can  sometimes  be  made  by 
the  excessive  tenderness  of  the  ovary. 

Treatment.  —  The  portion  of  the  ovary  in  which  the 
hematoma  is  found  should  be  resected. 


224:  DISEASES    OF    THE    OVAEIES 

CIRRHOSIS    OF    THE    OVARY 

When  the  ovary  is  cirrhotic  it  is  decreased  in  size,  is 
very  hard,  and  is  made  up  almost  entirely  of  dense  con- 
nective tissue.    The  Graafian  follicles  are  very  few. 

Symptoms.  —  Menstruation  is  usually  scanty  and  painful. 
There  is  more  or  less  constant  pelvic  pain.  These  patients 
are  commonly  nervous  and  irritable. 

Diagnosis.  —  On  bimanual  examination  the  ovary  is 
found  to  be  very  small,  very  hard,  and  tender  on  pressure. 

Treatment.  —  The  treatment  consists  of  the  resection  or 
entire  removal  of  the  affected  ovaries.  In  all  cases  where 
there  is  any  apparently  healthy  ovarian  tissue  present  it 
should  be  left. 

HYPERTROPHY    OF   THE    OVARY 

Hypertrophy  of  the  ovary  is  very  frequently  found  asso- 
ciated with  large  fibroids  of  the  uterus.  The  ovarian  ele- 
ments are  apparently  normal,  except  that  they  are  usually 
increased  both  in  number  and  size.  Enlarged  Graafian 
follicles  are  frequently  present  in  considerable  numbers. 
Hypertrophy  is  the  result  of  persistent  hyperemia  due  either 
to  infection  or  to  physiological  or  mechanical  influences. 

PROLAPSED    OVARIES 

Etiology.  —  A  very  large  proportion  of  prolapsed  ovaries 
occur  in  association  with  retrodisplacements  of  the  uterus. 
When  the  uterus  is  in  its  normal  position  the  prolapse  of 
the  ovary  may  be  due  to  the  increased  weight  of  the  ovary 
either  from  hypertrophy  or  from  the  development  of  small 
cysts.  The  prolapse  may  also  be  due  to  an  unusually  long 
utero-ovarian  ligament. 


PROLAPSED    OVARIES  225 

Symptoms.  —  Pain  in  the  pelvis  is  one  of  the  most  con- 
stant complaints.  It  may  be  referred  to  one  or  both  sides 
of  the  pelvis.  It  frequently  radiates  down  one  or  both 
legs  and  is  invariably  increased  by  the  patient's  being- 
much  on  her  feet.  There  is  pain  in  the  region  of  the 
sacrum  which  radiates  upward  and  is  associated  with  severe 
occipital  headache.  The  occipital  headache  is  paroxysmal 
and  is  exaggerated  at  the  menstrual  period. 

A  very  characteristic  symptom  is  a  severe  paroxysmal 
pain  in  the  pelvis  occurring  between  the  menstrual  periods. 
This  pain  comes  on  from  two  to  fourteen  days  before  or 
after  menstruation,  varying  in  different  cases,  but  its  period 
of  recurrence  in  each  case  is  very  constant.  It  is  severe  in 
character  and  continues  only  for  a  few  hours. 

Dysmenorrhea  is  usually  present.  Pain,  as  a  rule,  begins 
several  days  before  the  flow,  continues  through  the  period 
and  for  a  few  days  after  the  flow  has  ceased. 

The  nervous  symptoms  from  which  many  of  these  patients 
suffer  are  of  such  a  character  that  the  patients  are  not 
infrequently  classed  as  hysterical  or  neurasthenic.  It  is 
very  common  for  them  to  be  easily  excited  and  irritated, 
to  cry  without  provocation,  laugh  immoderately,  and  to  be 
in  a  generally  unstable  nervous  condition.  Occasionally 
convulsions  occur.  The  convulsions  have  a  tendency  to 
return  at  the  menstrual  period. 

Nausea  is  sometimes  complained  of.  It  is  increased  by 
the  patient's  being  in  the  erect  position.  Painful  coition  is 
frequently  complained  of.  Painful  defecation  is  also  com- 
mon. In  some  cases  the  pain  comes  on  during  the  act  of 
defecation,  and  with  some  the  pain  comes  just  after  the 
bowel  is  emptied  and  continues  for  some  minutes. 

Diagnosis.  —  The  diagnosis  is  usually  made  without  diffi- 
culty. The  prolapsed  ovary  can  be  felt  in  the  cul-de-sac 
directly  behind  the  uterus,  or  can  be  caught  between  the 


226 


DISEASES    OP    THE    OVAEIES 


fingers  in  the  vagina  and  the  lateral  pelvic  wall.  It  can  be 
recognized  by  its  tenderness  on  slight  pressure,  by  its  shape, 
and  by  its  tendency  to  slip  away  from  the  examining  finger. 
Treatment.  —  The  treatment  is  operative.  When  the 
ovaries  are  enlarged,  either  from  hypertrophy  or  from 
cystic  degeneration,  they  should  be  resected  to  decrease 
their  weight.  The  elongated  ovarian  ligament  is  then  short- 
ened by  a  couple  of  fine  silk  or  chromic  catgut  stitches. 
The  first  stitch  takes  a  light  firm  hold  in  the  uterus  near 
the  lower  border  of  the  ovarian  ligament.    It  is  then  con- 


Fig.  120.  —  Operation  for  Prolapsed  Ovary. 

tinued  through  a  portion  of  the  ligament  and  inserted 
firmly  into  the  ligament  near  the  ovary.  The  second  stitch 
is  placed  in  the  same  way  but  nearer  to  and  parallel  with 
the  upper  border  of  the  ligament.  When  these  stitches  are 
tied  the  ovary  is  brought  close  up  to  the  uterus,  but  it 
retains  a  limited  mobility  independent  of  the  uterus  and 
a  complete  mobility  with  the  uterus  (Fig.  120).  If  the 
prolapsed  ovaries  have  been  associated  with  a  retrodis- 
placement,  after  the  ovaries  are  fixed  to  the  uterus  the 
operator  can  proceed  to  do  the  operation  of  choice  for  the 
correction  of  the  displaced  uterus. 


CHAPTER    XVIII 

OVARIAN    CYSTS 

From  the  clinical  standpoint  a  satisfactory  method  of 
classifying  ovarian  cysts  is  to  divide  them  into  four  groups, 
—  unilocular,  multilocular,  papillomatous,  and  dermoid. 

Pathology.  —  Unilocular  cysts  develop  from  the  hilum 
of  the  ovary,  or  they  may  in  the  beginning  be  ordinary 
multilocular  cysts  in  which  one  cyst  has  developed  so  much 
more  rapidly  than  the  others  that  the  main  volume  of  the 
tumor  is  made  up  of  one  cyst.  They  are  usually  thin- 
walled  and  may  attain  a  large  size.  The  fluid  in  them 
is  usually  very  thin  and  very  light  in  color.  The  cyst  wall 
is  made  up  of  connective  tissue  and  usually  lined  by  a 
single  layer  of  columnar  epithelium.  In  the  larger  tumors 
the  epithelium  becomes  very  much  thinned  out  or  dis- 
appears. 

Multilocular  ovarian  cysts  or  adeno-cystomata  of  the 
ovaries  are  glandular  growths  that  develop  from  the  cortex. 
As  a  rule  they  have  a  dense  fibrous  capsule  which  is  of 
a  glistening  whitish  color.  When  the  capsule  is  thin  it 
is  sometimes  bluish  in  color.  The  surface  is  usually  lobu- 
lated.  This  lobulation  is  due  to  the  fact  that  the  tumor 
is  made  up  of  a  number  of  individual  cysts.  They  may 
attain  an  enormous  size.  The  fluid  contained  in  the  cyst 
is  identical  with  mucus  but  varies  greatly  in  consistence 
and  color.  It  may  be  thick  and  gelatinous  or  sufficiently 
thin  to  flow  very  freely.     It  varies  in  color  from  a  nearly 

227 


228 


OYAEIAK    CYSTS 


clear  fluid  to  almost  black.  The  variations  in  color  are 
due  to  the  mixture  of  the  contents  of  the  cyst  with  blood 
from  hemorrhages  into  the  cyst.  Many  variations  both 
in  color  and  consistence  may  be  found  in  the  different 


Fig.  121.  —  Multilocular  Ovarian  Cyst. 

cysts  of  the  same  tumor.     Multilocular  cysts  are  usually 
unilateral. 

On  microscopical  examination  the  cyst  wall  is  found  to 
be  made  up  mainly  of  connective  tissue.  In  exceptional 
instances  a  Graafian  follicle  may  be  found.  There  are 
present  in  the  cyst  wall  many  gland  spaces  lined  by  a 
single  layer  of  columnar  epithelium  (Fig.  122).  The  growth 
of  the  tumor  is  due  to  the  proliferation  of  the  glands  and 
the  filling  up  of  the  spaces  by  the  secretion  from  their 
lining  epithelium.    As  the  cysts  increase  in  size  and  pres- 


PATHOLOGY 


229 


sure   becomes   greater   the   epithelium   becomes   flattened. 
Later  it  may  entirely  disappear. 

Papillomatous  tumors  are  multilocular,  but  in  many  of 
them  one  cyst  develops  so  much  more  than  the  others  that 
they  are  apparently  unilocular.  They  are  characterized 
by  the  development  of  wart-like  growths  which  project 


Fig.   122.  —  Wall  op  Multilocular  Ovarian  Cyst.     (Photomicrograph.) 
Several  gland  spaces  surrounded  by  dense  connective  tissue  are  shown. 

into  the  cavity  of  the  cysts.  In  outer  appearance  many 
of  these  tumors  resemble  very  closely  the  ordinary  multi- 
locular cysts.  It  frequently  happens,  however,  that  the 
wall  of  one  cyst  ruptures.  The  papillomata  continue  to 
grow  through  the  rupture  and  on  the  outer  surface  of  the 
cyst  wall.  The  appearance  then  is  of  a  solid  or  semi-solid 
growth  covered  with  warts. 

The  papillomata  have  a  tendency  to  become  fixed  to  and 


230  OVAEIAN    CYSTS 

proliferate  on  any  surface  with  which  they  come  in  con- 
tact. It  is  not  unusual  to  see  them  growing  on  the  uterus, 
all  over  the  pelvic  peritoneum,  or  scattered  through  the 
abdominal  cavity.  They  may  recur  in  the  scar  of  the 
abdominal  wound  after  operations  for  their  removal.    These 


Fig.  123.  —  Papillomatous  Ovarian  Cyst. 

tumors  are  classified  as  benign  growths,  but  on  account 
of  the  tendency  of  the  papillomata  to  develop  on  any  tissues 
with  which  they  come  in  contact  they  are  to  be  dreaded 
almost  as  much  as  a  truly  malignant  tumor. 

Papillomatous  cysts  are  usually  bilateral.  These  tumors 
as  a  rule  do  not  grow  nearly  so  large  as  the  adeno-cysto- 
mata.  Many  of  them  have  their  origin  near  the  hilum  of 
the  ovary  and  grow  downward  into  the  broad  ligament. 
The  fluid  in  the  cyst  is  usually  very  thin  and  of  a  light 
color.    The  cyst  wall  is  made  up  of  connective  tissue  which 


PATHOLOGY 


231 


is  well  supplied  with  blood-vessels.  The  papillary  growths 
consist  of  a  connective  tissue  stem  supplied  by  blood-vessels 
and  covered  on  the  outer  side  with  columnar  epithelium 
(Fig.  124). 

A  dermoid  cyst,  as  the  name  suggests,  is  one  in  which  epi- 
dermal growths  are  found.     These  include  skin,  sebaceous 


Fig.  124.  —  Wall  of  Papillomatous  Ovarian  Cyst.  (Photomicrograph.) 
A  segment  of  the  cyst  wall  from  which  grows  a  single  connective  tissue  stem  with 
numerous  branches  covered  with  epithelium  is  shown. 


glands,  hair,  teeth,  bones,  and  sometimes  nails.  Very  rarely 
partially  developed  mammary  and  thyroid  glands  are  pres- 
ent. The  skin  found  in  these  growths  varies  in  thickness. 
It  is  sometimes  pigmented  and  has  a  stratified  squamous 
epithelium.  The  amount  of  hair  present  is  extremely  vari- 
able. There  may  be  very  little,  or  it  may  be  present  in 
large  quantities  and  very  long.     The  color  of  the  hair  in 


232  OVAKIAN    CYSTS 

the  dermoid  has  no  definite  relation  to  the  color  of  the 
hair  of  the  individual  in  whom  it  is  found.  It  is  said  to 
turn  white  when  the  carrier  becomes  old.  The  sebaceous 
glands  are  very  numerous  and  the  secretion  from  them 
forms  considerable  masses  within  the  cyst.  The  number 
of  teeth  present  may  vary  from  two  to  several  hundred. 
It  is  unusual  to  find  more  than  a  dozen.    They  are  usually 


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V  'ma   •"   ^Ci* 

r  -      V 

K     i 

•'A 

•:•..  .■■"$& 

5T*     •  -          M 

N 

'  m 

^ 

4 

^ 

|K|  »9 

Fig.  125.  —  Ovarian  Dermoid. 

collected  in  one  or  two  groups  in  the  tumor  and  may 
be  imbedded  in  soft  tissue  or  in  bone.  The  bone  present 
in  ovarian  dermoids  is  usually  shapeless.  The  walls  of 
dermoid  cysts  are  usually  thick  and  yellowish  in  color. 
The  contents  of  the  cysts  are  made  up  of  sebaceous  matter, 
exfoliated  hair,  and  epithelium.  The  exfoliated  epithelium 
is  frequently  present  in  the  form  of  numerous  balls.  The 
fluid  contents  of  the  cysts  is  very  irritating  to  the  perito- 
neum. These  cysts  frequently  become  infected.  They  are 
usually  unilateral,  but  may  be  bilateral. 


SYMPTOMS  233 

Pedicle.  —  The  pedicle  of  an  ovarian  tumor  consists  of 
the  Fallopian  tube  and  an  elongated  portion  of  the  broad 
ligament.  In  simple  cases  it  is  drawn  out  into  a  relatively 
narrow  body.  In  some  instances  the  tumor  grows  down 
between  the  layers  of  the  broad  ligament.  In  these  cases 
there  is  no  pedicle  proper.  Usually,  however,  the  outer 
portion  of  the  broad  ligament  which  carries  the  ovarian 
artery  near  its  upper  border  can  be  isolated  so  the  artery 
can  be  clamped. 

Rate  of  Growth.  —  The  rate  of  growth  of  all  ovarian  cys- 
tomata  is  extremely  variable.  The  adeno-cystomata  grow 
more  rapidly  than  the  other  forms,  but  there  is  no  regu- 
larity in  the  rate  of  their  development.  Some  grow  so 
rapidly  that  in  a  few  weeks  the  whole  abdomen  is  filled. 
Others  may  be  present  for  long  periods  before  attaining 
sufficient  size  to  inconvenience  the  patient.  Papillomata 
grow  more  slowly  and  do  not  attain  the  size  of  the  adeno- 
cystomata.  Once  started,  however,  there  is  little  tendency 
for  them  to  stop  in  the  course  of  their  development.  Der- 
moids frequently  remain  latent  for  long  periods  and  then 
in  a  comparatively  short  time  develop  into  tumors  of  con- 
siderable size. 

Symptoms.  —  As  a  rule,  the  first  symptom  that  is  noted 
by  the  patient  who  has  an  ovarian  tumor  is  an  enlargement 
in  the  abdomen.  There  may  be  more  or  less  abdominal 
discomfort  of  an  indefinite  nature.  Vesical  tenesmus  from 
pressure  is  sometimes  noted.  Menstruation  may  not  be 
affected  at  all.  In  some  cases  it  is  increased  in  quantity. 
Occasionally  there  is  a  dysmenorrhea.  The  most  impor- 
tant secondary  result  of  the  increase  in  size  of  an  abdominal 
growth  is  the  interference  with  digestion.  This  is  probably 
a  purely  mechanical  result  of  the  pressure  of  the  tumor 
upon  the  stomach  and  intestines.  The  multilocular  ovarian 
cyst  produces  a  definite  toxemia  which  results  in  malnu- 


234 


OVAEIAN    CYSTS 


trition.  The  patient  loses  weight  rapidly.  There  is  a 
pinched  and  drawn  expression  of  the  face.  Papillomatous 
tumors  cause  ascites,  and  wherever  there  is  ascites  and  an 
absence  of  any  demonstrable  lesion  of  the  liver,  kidneys, 
or  heart,  an  ovarian  papillomata  may  be  suspected. 

Diagnosis.  —  Before  beginning  the  physical  examination 
of  these  patients  the  clothing  should  be  removed,  the  rec- 
tum and  bladder  emptied,  and  the  patient  placed  in  the 
extended  dorsal  position  on  a  firm  table. 


Fig.  126.  —  Outline  of  Abdomen  Containing  an  Ovarian  Tumor. 

Ovarian  cystomata  develop  from  the  pelvis  upward  into 
the  abdominal  cavity. 

The  contour  of  the  abdomen  as  noted  by  inspection  varies 
with  the  size  and  density  of  the  growth.  In  the  earlier 
stages  of  the  growth  the  enlargement  in  the  abdomen  is 
usually  a  little  to  one  side  of  the  median  line  and  just 
above  the  brim  of  the  pelvis.  When  the  tumor  is  of  mod- 
erate size  the  lower  half  of  the  abdominal  wall  is  elevated. 
This  elevation  is  dome-shaped  (Fig.  126).  Very  large 
tumors  assume  the  median  line  and  may  distend  the  ab- 
dominal wall  from  the  pubes  to  the  ensiform  appendix. 
The  unilocular  cysts  are  thin-walled  and  usually  less  tensely 
distended  than  the  multilocular  cysts.    The  pressure  of  the 


DIFFERENTIAL    DIAGNOSIS  235 

abdominal  wall  has  a  tendency  to  flatten  them.  Conse- 
quently they  are  less  prominent  than  the  multilocular  cysts. 
When  the  tumor  does  not  entirely  fill  the  abdominal  cavity 
that  part  of  the  abdominal  wall  lying  directly  over  the 
tumor  moves  little  or  none  with  inspiration  and  expiration, 
while  the  upper  abdominal  wall  rises  and  falls  regularly 
with  the  breathing. 

By  palpation  the  outlines  of  the  tumor  can  usually  be 
made  out,  although  when  a  thin-walled  unilocular  cyst  or 
a  very  large  multilocular  cyst  is  present,  the  outlines  of  the 
tumor  may  be  very  indistinct.  Fluctuation  can  usually  be 
recognized.  It  is  very  much  more  pronounced  in  unilocular 
than  in  multilocular  cysts. 

On  percussion  the  area  of  dullness  extends  from  the 
pubes  to  near  the  upper  border  of  the  tumor  and  laterally 
from  the  median  line  to  near  the  lateral  borders  of  the 
tumor.  The  flanks  and  epigastric  region  are  tympanitic. 
The  location  of  the  areas  of  dullness  and  tympany  are  not 
materially  modified  by  change  in  the  position  of  the  patient. 

On  vaginal  examination  a  normal-sized  uterus  can  be 
found  in  the  pelvis.  If  the  tumor  is  one  that  is  readily 
movable,  by  pushing  it  up  with  the  hand  over  the  abdomen 
and  at  the  same  time  drawing  down  the  uterus  with  a 
tenaculum,  the  pedicle  may  be  felt  either  through  the  rectal 
or  the  vaginal  wall. 

Differential  Diagnosis.  —  Other  conditions  that  produce 
enlargement  of  the  abdomen  and  which  must  be  differen- 
tiated from  ovarian  tumors  are  pregnancy;  large  uterine 
fibroids ;  ascites ;  fat  abdominal  wall ;  distended  intestines ; 
tuberculous  peritonitis  with  encysted  fluid ;  distended  blad- 
der;  and  occasionally  renal,  hepatic,  and  splenic  cysts. 

Pregnancy.  —  In  pregnancy  there  is  a  history  of  cessa- 
tion of  the  menses.  The  breasts  are  enlarged  and  tender. 
There  is  an  increased  pigmentation  around  the  nipples; 


236  OVAEIAN    CYSTS 

the  papillae  around  the  nipples  are  enlarged.  There  is  some 
secretion  in  the  breasts.  On  inspection  of  the  abdomen 
it  is  noted  that  there  is  an  increase  of  pigmentation  in  the 
median  line.  The  general  contour  of  the  abdomen  and  the 
areas  of  dullness  and  tympany  elicited  by  percussion  are 
just  the  same  as  when  an  ovarian  tumor  is  present.  On 
palpation  intermittent  uterine  contractions  are  noted.  Ordi- 
narily the  solid  body  of  the  fetus  floating  within  a  cystic 
tumor  can  be  made  out.  By  auscultation  during  the  latter 
part  of  pregnancy  the  fetal  heart  sound  can  nearly  always 


Fig.  127.  —  Outline  of  Abdomen  with  Ascites. 

be  detected.  The  vagina  and  cervix  are  discolored.  On 
digital  examination  the  cervical  tissues  around  the  external 
os  are  found  to  be  soft;  the  cervical  canal  is  patulous. 
It  is  noted  that  the  tumor  is  directly  continuous  with  the 
cervix.  It  can  be  determined  that  the  tumor  present  is 
a  cystic  tumor  of  the  uterus.  Some  portion  of  the  fetus 
can  usually  be  felt  through  the  vaginal  wall. 

Uterine  Fibroids.  —  A  uterine  fibroid  is  recognized  as 
a  solid  uterine  growth.  When  the  tumor  itself  is  moved  by 
one  hand  over  the  abdominal  wall  the  cervix  and  that  por- 
tion of  the  tumor  that  can  be  felt  by  vaginal  examination 
will  be  found  to  move  at  the  same  time.     There  is  no 


DIFFERENTIAL    DIAGNOSIS  237 

normal-sized  uterus  to  be  felt  below  the  tumor  as  there 
is  when  the  enlargement  is  an  ovarian  cyst.  There  is 
usually  more  disturbance  of  menstruation  with  fibroids  than 
with  ovarian  tumors.  Fibroids  develop  more  slowly  than 
ovarian  tumors. 

Ascites.  —  In  ascites  the  abdomen  is  flat  and  the  flanks 
bulge  (Fig.  127).  No  definite  tumor  mass  can  be  felt  by 
palpation.  Fluctuation  can  usually  be  made  out.  On  per- 
cussion the  most  dependent  parts  are  dull  and  the  most 
elevated  portions  in  the  abdominal  wall  are  tympanitic. 
This  is  just  the  reverse  of  the  areas  of  dullness  and  tym- 
pany when  an  ovarian  tumor  is  present.  By  changing  the 
position  of  the  patient  the  relative  areas  of  dullness  and 
tympany  change.  The  area  of  dullness  on  the  dependent 
side  increases,  while  on  the  elevated  side  the  percussion 
note  becomes  tympanitic. 

In  exceptional  cases,  when  there  is  a  very  great  accumu- 
lation of  ascitic  fluid,  the  abdominal  wall  is  pushed  so  far 
forward  that  the  mesentery  prevents  the  intestines  from 
coming  in  contact  with  it.  The  whole  abdomen  is  then  dull 
on  percussion.  Some  of  these  cases  are  difficult  to  differ- 
entiate from  very  large  ovarian  tumors  that  have  developed 
rapidly. 

Fat  Abdominal  Wall.  —  This  condition  can  usually  be 
recognized  by  noting  the  deposits  of  fat  in  other  portions 
of  the  body.  By  grasping  a  fold  of  the  abdominal  wall 
between  the  two  hands  the  thickness  of  it  can  be  readily 
determined. 

Distended  Intestines.  —  When  the  abdominal  enlarge- 
ment is  due  to  the  distention  of  the  intestines  the  tym- 
panitic area  extends  over  the  whole  abdominal  wall.  The 
absence  of  a  tumor  can  be  recognized  by  pressing  with 
the  hand  firmty  downward  in  the  median  line  of  the  abdo- 
men until  the  vertebral  column  is  felt.    In  exceptional  cases 


238  OVAEIAN"    CYSTS 

it  may  be  necessary  to  examine  these  patients  under  an 
anesthetic. 

Tuberculous  Peritonitis.  —  Occasionally  as  a  result  of 
tuberculous  peritonitis,  closed-ofr  cavities  within  which 
fluid  accumulates  are  formed.  These  may  distend  the  abdo- 
men and  very  closely  resemble  in  outline  an  ovarian  tumor. 
The  formation  of  these  cysts  is  always  preceded  by  an 
active  tuberculous  peritonitis,  of  which  a  history  can  usually 
be  obtained.  They  are  also  usually  associated  with  other 
definite  indications  of  tuberculous  peritonitis.  They  are 
fixed  in  their  position.  Usually  they  do  not  give  the  his- 
tory of  a  tumor  that  has  developed  upward  into  the  abdomen 
from  the  pelvis. 

Distended  Bladder.  —  A  distended  bladder  forms  an 
ovoid  cystic  tumor  in  the  median  line  of  the  abdomen  which 
may  extend  as  high  as  the  umbilicus.  Over-distention  of 
the  bladder  is  usually  due  either  to  a  retroverted  pregnant 
uterus  or  to  an  adherent  pelvic  ovarian  tumor.  Excep- 
tionally it  may  become  over-distended  from  atony.  When 
the  bladder  is  over-distended  there  is  usually  a  constant 
dribbling  of  urine  which  leads  the  patient  to  think  that 
the  bladder  is  empty.  In  attempting  to  relieve  an  over- 
distended  bladder  a  male  soft-rubber  catheter  should  be 
used.  It  must  be  inserted  far  enough  to  reach  beyond  the 
point  of  obstruction.  The  evacuation  of  the  bladder  clears 
up  the  diagnosis. 

Complications.  —  The  most  frequent  complications  of 
ovarian  tumors  are  twisted  pedicle,  adhesions,  infections, 
ruptures,  and  malignancy. 

Twisted  Pedicle.  —  When  the  pedicle  of  an  ovarian  tumor 
becomes  twisted  the  circulation  is  interfered  with  and  occa- 
sionally the  blood  supply  is  entirely  cut  off.  When  the 
blood  supply  is  interfered  with  only  to  a  limited  extent 
the  tumor  becomes  congested,  dark  in  color,  and  as  a  rule 


COMPLICATIONS 


239 


hemorrhages  take  place  into  it.  If  the  blood  supply  is 
entirely  cut  off,  gangrene  results.  When  a  pedicle  becomes 
twisted  the  patient  complains  of  a  sharp  pain  coming  on 
suddenly.  The  abdomen  enlarges  rapidly  and  becomes 
tender.  The  severity  of  these  symptoms  varies  with  the 
extent  to  which  the  circulation  in  the  pedicle  is  interfered 
with.    When  the  patient  is  known  to  have  had  an  ovarian 


J 


mi 

Fig.  128.  —  Carcinoma  of  the  Ovary  Developing  from  Papillomatous 
Cyst.     (Photomicrograph.) 

tumor  the  twisting  of  the  pedicle  can  usually  be  recognized 
by  the  sudden  onset  of  pain,  tenderness,  and  distention. 

Adhesions.  —  Adhesions  between  ovarian  tumors  and 
other  pelvic  and  abdominal  viscera  may  be  due  to  infection 
communicated  from  the  Fallopian  tubes  or  from  the  in- 
testinal canal.  They  are  sometimes  due  to  the  irritation 
produced  by  the  tumor  itself  exclusive  of  any  definite  in- 
fection. Adherent  ovarian  tumors  can  only  be  recognized 
before  operation  when  the  tumors  are  of  such  size  that 
they  would  under  ordinary  circumstances  be  easily  movable. 


240 


OVAKIAN    CYSTS 


Infections.  —  Ovarian  tumors  may  become  infected  from 
the  -  Fallopian  tubes,  by  continuity  through  the  intestinal 
wall,  or  by  an  infection  carried  by  the  blood  stream.  Der- 
moid cysts  are  more  frequently  infected  than  any  other 
kind. 

Euptuees.  —  Ruptures  of  ovarian  cysts  are  usually  due 
to  blows  or  falls.    A  rupture  can  usually  be  recognized  by 


Fig.  129.  —  Carcinoma  op  the  Ovary  Developing  from  an  Adeno-cys- 
toma.     (Photomicrograph.) 

the  loss  of  the  tumor  outline  and  evidence  of  free  fluid 
in  the  peritoneal  cavity.  The  fluid  from  multilocular  cysts 
is  non-irritating  to  the  peritoneum  and  its  presence  gives 
rise  to  no  symptoms,  but  it  is  not  absorbed.  If  the  rupture 
takes  place  at  a  position  in  the  cyst  wall  where  there  are 
no  blood-vessels  of  importance,  the  patient  may  have  only 
slight  discomfort  at  the  time.  The  cyst  continues  to  secrete 
and  the  abdomen  gradually  fills  up.    If  the  rupture  should 


COMPLICATIONS 


241 


take  place  at  a  position  in  the  cyst  wall  where  there  are 
large  vessels,  there  may  be  such  a  profuse  hemorrhage 
into  the  abdominal  cavity  as  to  cause  death. 

Malignancy.  —  About  twenty-five  per  cent  of  all  ovarian 
cystomata  are  malignant.  Carcinomata  and  sarcomata  are 
the  forms  most  frequently  found,  but  some  of  the  rarer 
malignant  growths  are  also  met  with.    Carcinomata  develop 


Fig.  130.  —  Sarcoma  of  the  Ovary.    The  section  is  from  a  cyst  wall. 


from  the  abundant  epithelium  present  both  in  the  adeno- 
cystomata  (Fig.  129)  and  the  papillomata  (Fig.  128).  The 
sarcomata  (Fig.  130)  have  their  origin  in  the  cyst  walls. 
As  a  rule  there  is  nothing  to  distinguish  the  malignant  from 
the  non-malignant  tumors  before  the  abdomen  is  opened. 
"When  a  solid  mass  is  found  in  one  part  of  an  ovarian 
cyst  malignancy  should  be  suspected.  The  diagnosis  of 
malignancy  is  frequently  not  made  until  after  the  tumor 
has  been  removed. 


242  OVAEIAN    CYSTS 

Prognosis.  —  There  is  only  one  definite  statement  that 
can  be  made  as  to  what  will  result  from  an  ovarian  cystoma 
which  is  not  removed,  and  that  is,  that  it  will  surely  cause 
the  death  of  the  patient.  If  she  escape  the  dangers  of 
infection,  twisted  pedicle,  rupture,  and  malignancy  there 
is  no  escape  from  the  toxemia  and  profound  digestive  dis- 
turbances. These  latter  may  be  the  direct  cause  of  death, 
or  they  may  so  weaken  the  sufferer  that  some  trifling  inter- 
current malady  may  cause  a  fatal  termination. 

Treatment.  —  All  ovarian  tumors  should  be  removed 
through  an  abdominal  incision.  This  incision  is  made  in 
the  median  line  between  the  umbilicus  and  the  symphysis. 
The  first  incision  should  be  large  enough  to  allow  the  intro- 
duction of  the  hand  into  the  abdominal  cavity.  The  hand 
should  be  introduced  and  passed  over  the  surface  of  the 
tumor  to  locate  any  adhesions,  to  determine  the  character 
of  the  pedicle,  and  to  seek  for  any  indication  of  malignancy 
or  infection.  If  the  tumor  is  made  up  of  a  single  thin- 
walled  cyst  the  intestines  are  packed  off  and  the  cyst 
punctured  with  a  knife.  By  making  pressure  on  the  sides 
of  the  tumor  through  the  abdominal  wall  the  fluid  contents 
can  be  forced  out  through  the  small  opening  in  the  cyst 
wall  and  caught  in  a  basin.  As  the  tumor  collapses  the 
cyst  wall  can  be  drawn  out  through  the  abdominal 
incision.  The  pedicle  is  then  clamped  and  the  sac 
excised.  The  pedicle  should  be  tied  off  in  sections, 
taking  care  not  to  include  too  large  a  portion  in  any  one 
ligature. 

Unfortunately  this  extremely  simple  operation  is  not 
applicable  to  a  very  large  proportion  of  ovarian  cystomata. 
It  should  not  be  attempted  in  dermoids,  in  papillomata,  nor 
in  adeno-cystomata  which  have  a  solid  growth  in  one  side 
of  them.  It  is  also  not  applicable  to  infected  ovarian  tumors 
or  to  those  which  are  clearly  malignant.    All  of  these  tumors 


TREATMENT  243 

should  be  removed  through  an  abdominal  incision  long 
enough  to  allow  the  delivery  of  the  entire  tumor  without 
breaking  the  cyst  wall.  In  all  cases  where  there  is  any 
doubt  as  to  the  character  of  the  contents  of  the  tumor, 
it  should  be  removed  through  the  long  incision. 

Adhesions  between  the  sac  and  the  parietes  or  between 
the  sac  and  the  contents  of  the  abdominal  cavity  are  the 
most  common  obstacles  in  the  delivery  of  ovarian  cysts. 
When  the  adhesions  are  over  the  front  of  the  tumor  it 
makes  it  very  difficult  to  determine  when  the  incision  is 
through  the  peritoneum.  The  stripping  of  the  peritoneum 
from  the  abdominal  wall  in  attempts  to  separate  the  adhe- 
sions has  been  done  many  times.  Intestinal  adhesions  can 
usually  be  separated  from  the  sac  wall  with  a  piece  of 
gauze  over  the  finger.  When  the  adhesions  are  very  firm 
it  may  be  necessary  to  separate  the  adhesions  with  a  knife. 
When  this  is  done,  care  should  always  be  taken  to  make 
the  dissection  at  the  expense  of  the  cyst  wall.  All  bleed- 
ing points  that  are  caused  by  the  separation  of  adhesions 
should  be  secured  immediately.  If  the  vessels  are  of  con- 
siderable size  they  should  be  tied  with  fine  catgut.  Oozing 
from  very  small  vessels  can  usually  be  checked  by  pressure 
with  gauze.  Omental  adhesions  are  best  separated  by  rub- 
bing them  off  with  a  piece  of  dry  gauze.  When  the  sepa- 
rated omental  surface  has  a  tendency  to  ooze  freely  it  should 
be  firmly  ligated. 

In  those  cases  in  which  the  tumor  has  grown  down  be- 
tween the  layers  of  the  broad  ligament,  it  is  usually  possible 
to  isolate  and  secure  the  ovarian  artery  near  the  pelvic 
wall.  When  this  is  done,  an  incision  can  be  made  between 
the  ligature  and  the  tumor.  The  tumor  is  then  dissected 
upwards,  and  the  vessels  entering  it  near  the  uterus  can  be 
secured.  In  exceptional  cases  the  growth  penetrates  so 
near  the  large  blood-vessels  that  it  is  safer  to  excise  the 


244  OVAEIAN"    CYSTS 

major  portion  of  the  cyst  wall  and  leave  the  remainder 
behind;  but  this  should  not  be  done  if  it  can  possibly  be 
avoided.  When  an  ovarian  cyst  complicates  a  pregnancy 
it  should  be  removed  in  the  same  manner  as  if  the  patient 
were  not  pregnant. 


CHAPTER   XIX 

SOLID     OVARIAN    TUMORS,     PAROVARIAN     CYSTS,  AND    TUMORS    OF 
THE   BROAD    LIGAMENTS 

SOLID   TUMORS   OF   THE   OVARY 

About  five  per  cent  of  all  ovarian  tumors  are  solid. 
They  include  fibromata,  papillomata,  carcinomata,  and 
sarcomata. 


Fig.  131.  —  Ovarian  Fibroid. 

Fibromata.  —  Ovarian  fibroids  are  histologically  identi- 
cal with  uterine  fibroids.  They  may  involve  only  a  portion 
of  the  ovary  or  the  whole  of  it.  They  sometimes  attain  a 
very  considerable  size.    When  they  are  small  and  involve 

245 


2-16 


TUMORS    OF    OYAEY    AND    LIGAMENTS 


only  a  portion  of  the  ovary,  they  give  rise  to  pain  and  the 
affected  ovary  is  tender  on  pressure.  The  larger  ones  that 
involve  the  whole  ovary  usually  cannot  be  differentiated 
before  the  abdomen  is  opened  from  pedunculated  uterine 
fibroids. 

Papillomata.  —  Solid  papillomatous  tumors  are  found, 
but  they  were  almost  certainly  originally  cystomata  that 
have  ruptured.     The  cyst  cavity  not  having  refilled,  the 


Fig.  132.  —  Solid  Ovarian  Carcinoma. 
together  in  a  mass  behind  the  uterus. 


Both  ovaries  are  involved  and  fused 


papillomata  continue  to  grow  on  the  outer  side.  They  have 
a  tendency  to  spread  to  all  the  tissues  with  which  they  come 
in  contact.  They  cause  accumulation  of  much  ascitic  fluid. 
When  a  small  pelvic  tumor  can  be  made  out  that  is  asso- 
ciated with  ascites,  papillomata  should  always  be  suspected. 
Carcinomata.  —  Solid  ovarian  carcinomata  are  nearly 
always  bilateral.  Practically  all  bilateral  solid  carcinomata 
are  metastatic  growths  (Figs.  132  and  133).    The  primary 


SOLID    TUMORS    OF    THE    OVAEY 


24; 


carcinoma  from  which  the  ovaries  become  infected  is  usually 
seated  in  the  stomach,  gall  bladder,  or  other  structures  in 
the  upper  abdomen.  Metastasis  from  the  upper  abdomen 
to  the  ovaries  apparently  takes  place  much  more  frequently 
before  than  after  the  menopause. 


Fig.  133.  —  Solid  Ovarian  Carcimona.  (Photomicrograph.)  The  slide  was 
made  from  the  tumor  shown  in  Fig.  132. 

Sarcomata.  —  Solid  sarcomata  of  the  ovaries  are  very 
rare.  They  may  occur  at  any  age.  They  are  usually  of 
the  spindle-cell  variety.     They  grow  very  rapidly. 

Treatment.  —  All  solid  ovarian  tumors  should  be  re- 
moved by  abdominal  section.  In  cases  of  bilateral  solid 
carcinomata  very  little  is  to  be  expected  from  their  removal 
unless  the  primary  carcinoma  is  also  removed.  When  these 
carcinomata  are  discovered  at  operation  the  upper  abdomen 
should  always  be  carefully  explored. 


248  TUMOKS    OF    OVAEY    AND    LIGAMENTS 

PAROVARIAN   CYSTS 

The  parovarium  lies  in  the  broad  ligament  just  between 
the  ovary  and  the  Fallopian  tube.  It  consists  of  the  remains 
of  Gartner's  duct  which,  in  that  part  of  its  course,  runs 
parallel  with  the  Fallopian  tube,  and  a  series  of  short 
tubules  which  join  it  at  right  angles  and  are  known  as 
Pfliiger's  tubules. 

The  cysts  of  the  parovarium  develop  from  either  Gart- 
ner's duct  or  one  of  the  tubules   of  Pfliiger.     They  are 


G 
Fig.  134.  —  The  Parovarium. 

usually  not  pedunculated,  and  are  spread  out  between  the 
layers  of  the  broad  ligament.  They  are  very  thin-walled, 
and  over  them  they  have  a  non-adherent  layer  of  peri- 
toneum which  is  a  portion  of  the  distended  broad  ligament. 
The  fluid  in  them  is  thin  and  clear.  The  Fallopian  tube  is 
stretched  out  over  the  tumor  and  the  ovary  is  not  affected. 
They  grow  very  slowly.  They  are  sometimes  associated 
with  cysts  in  the  anterior  vaginal  wall  which  are  dilatations 
of  the  lower  portion  of  Gartner's  duct. 

Symptoms.  —  The  symptoms  produced  by  parovarian 
cysts  are  due  to  the  pressure  they  exert  on  other  pelvic 
organs.  As  they  become  larger  they  extend  up  into  the 
abdomen.  They  may  cause  constipation  by  direct  pressure 
upon  the  rectum.  They  often  cause  frequent  urination  by 
pressing  the  bladder  against  the  pubes. 


SOLID    TUMORS    OF    BROAD   LIGAMENT  249 

Diagnosis.  —  It  is  not  always  possible  to  distinguish 
parovarian  cysts  from  ovarian  tumors,  but  their  fixed  posi- 
tion, thin  walls,  fluctuating  contents,  and  slow  growth  help 
to  identify  them. 

Treatment.  —  After  the  abdomen  is  opened  it  is  usually 
possible  to  split  that  part  of  the  broad  ligament  which  is 


Fig.  135.  —  Parovarian  Cyst. 

stretched  over  the  most  prominent  portion  of  the  tumor 
and  enucleate  the  tumor.  The  opening  in  the  broad  liga- 
ment is  then  closed  with  fine  catgut. 


SOLID    TUMORS    OF   THE    BROAD    LIGAMENT 

Fibroids,  sarcomata,  carcinomata,  and  hypernephromata 
all  are  found  occasionally  in  the  broad  ligaments.  A  diag- 
nosis is  rarely  made  of  any  of  them  until  after  removal. 
Most  of  them  require  a  microscopical  examination  of  the 
tumor  to  determine  their  character.  The  only  method  of 
treatment  is  to  remove  the  tumor  bv  abdominal  section. 


250  TUMOES    OF    OVARY    AND    LIGAMENTS 

VARICOCELE    OF    THE    BROAD    LIGAMENT 

Varicocele  of  the  broad  ligament  occurs  with  relative  fre- 
quency. The  veins  most  frequently  dilated  are  those  in 
the  upper  part  of  the  broad  ligament,  although  all  the 
veins  in  both  broad  ligaments  may  be  involved. 

Etiology.  —  Varicose  veins  of  the  broad  ligaments  occur 
most  frequently  in  women  who  have  borne  children.  Uter- 
ine displacements  favor  their  development.  Large  fibroids 
of  the  uterus  nearly  always  have  associated  with  them 
varicose  veins  of  the  broad  ligaments.    In  a  considerable 


Fig.  136.  —  Varicocele  of  the  Broad  Ligament. 

proportion  of  cases  no  definite  cause  can  be  assigned  for 
their  presence. 

Symptoms.  —  There  is  usually  a  dull  pelvic  pain  which 
is  exaggerated  by  standing  or  walking.  The  menstrual 
flow  is  increased.  There  is  a  tendency  to  post-partum 
hemorrhage. 

Diagnosis.  —  The  diagnosis  can  sometimes  be  made 
if  in  connection  with  the  already  mentioned  symptoms 
a  somewhat  boggy  mass  can  be  felt  on  one  or  both 
sides  of  the  uterus.  Usually,  however,  the  diagnosis 
is  made  by  inspection  after  the  abdomen  has  been 
opened. 

Treatment.  —  When  there  are  no  indications  for  the  re- 


VARICOCELE    OF    THE    BROAD    LIGAMENT         251 

moval  of  either  the  tubes  or  ovaries  the  enlarged  veins  can 
be  tied  both  at  the  outer  and  inner  sides  of  the  broad  liga- 
ment and  resected.  In  patients  who  are  past  the  meno- 
pause it  is  sometimes  advisable  to  do  a  supravaginal 
hysterectomy. 


CHAPTER   XX 

TECHNIQUE 

ABDOMINAL   OPERATIONS 

Place  of  Operation.  —  It  is  much  more  satisfactory  to  do 
all  operations  in  a  well-equipped  hospital;  but  under  cer- 
tain circumstances  this  is  impossible,  and  it  is  necessary 
to  operate  in  the  home  of  the  patient. 

The  room  selected  for  the  operation  should  be  well 
lighted  and  everything  movable  should  be  taken  out  of  it, 
the  floor  scrubbed,  and  the  walls  wiped  down.  There 
should  be  an  abundant  supply  of  hot  and  cold  sterile  water. 
A  small  kitchen  table  makes  the  best  substitute  for  an 
operating  table.  There  should  be  one  or  two  other  small 
tables  present  for  instruments  and  dressings.  All  the  dress- 
ings, towels,  and  sheets  that  are  required  should  be  sterilized 
beforehand.  The  instruments  can  be  sterilized  either  before 
going  to  the  place  of  operation  or  by  boiling  them  after 
arriving  there. 

Time  of  Operation.  —  The  best  time  of  the  day  for  opera- 
tive work  is  the  morning.  It  relieves  the  patient  of  a  long 
wait,  and  the  patient,  the  operator,  and  his  assistants  are 
all  in  better  physical  condition  early  in  the  morning  than 
at  any  other  time  of  the  day.  All  operations  which  are 
not  emergency  operations  should  be  fixed  at  a  time  that 
is  not  too  close  to  the  menstrual  period. 

Preparation  of  Patient.  —  The  diet  for  twenty-four  hours 
before  operation  should  not  include  anything  that  is  par- 

252 


ABDOMINAL    OPERATIONS  253 

ticularly  indigestible.  The  patient  should  have  a  fair 
amount  of  plain  food.  A  laxative  should  be  given  the 
day  before  operation  and  a  soap  and  water  enema  the 
morning  of  the  operation.  Excessive  purgation  just  before 
operation  should  be  avoided.  Immediately  before  the  oper- 
ation, the  bladder  should  be  emptied  voluntarily  or  by  the 
catheter.  At  the  same  time  a  vaginal  douche  of  one  to 
four  thousand  bichloride  followed  by  sterile  water  should 
be  given.  The  evening  before  the  operation  the  patient 
should  have  a  full  bath  and  the  field  of  operation  should 
be  thoroughly  scrubbed  and  shaved.  After  the  anesthetic 
is  started  the  field  of  operation  should  be  again  thoroughly 
scrubbed  with  soap  and  water.  Gauze  is  better  than  a 
brush  for  scrubbing  the  abdomen.  The  soap  is  thoroughly 
rinsed  off.  This  is  followed  by  ether  to  remove  any  re- 
mainder of  the  fats  and  soap.  The  surface  should  then 
be  washed  off  with  seventy  per  cent  alcohol  and  covered 
for  a  few  minutes  with  a  piece  of  gauze  saturated  with 
one  to  two  thousand  bichloride  of  mercury  solution. 

Preparation  of  Instruments,  etc.  —  Instruments  are  best 
sterilized  by  boiling  them  fifteen  minutes  in  a  solution  of 
bicarbonate  of  soda.  Gauze  sponges,  abdominal  packs, 
dressings,  towels,  and  sheets  are  best  sterilized  by  steam. 
These  are  all  put  up  in  separate  packages  and  marked 
before  sterilization,  and  not  opened  until  they  are  ready 
for  use. 

Preparation  of  the  Operator  and  Assistants.  —  The  oper- 
ator and  all  assistants  should  thoroughly  scrub  their  hands 
with  soap  and  warm  water,  particular  attention  being  paid 
to  the  finger-nails.  The  hands  are  then  washed  in  a  warm 
solution  of  one  to  two  thousand  bichloride  of  mercury 
and  rinsed  off  with  seventy  per  cent  alcohol.  A  long-sleeved 
gown  is  put  on  and  rubber  gloves  with  gauntlets  that  come 
up  over  the  sleeves  of  the  gown.    A  cap  with  a  mask  at- 


254  TECHNIQUE 

tacked  to  cover  the  mouth  and  nose  is  worn.  The  gloves 
may  be  sterilized  by  boiling,  and  the  cap  and  gown  may 
be  sterilized  by  steam  along  with  the  sponges. 

Anesthesia.  —  Under  special  conditions  it  may  be  satis- 
factory to  operate  under  a  local  anesthetic,  but  ordinarily 
a  general  anesthetic  is  more  satisfactory,  and  for  this 
purpose  ether  administered  by  the  drop  method  can  be 
used  in  a  greater  proportion  of  cases  than  any  other  anes- 
thetic. Chloroform  is  preferred  by  some  operators,  but 
ether  is  undoubtedly  safer. 

Position  of  Patient.  —  The  Trendelenburg  position  is  the 
one  ordinarily  employed  for  all  pelvic  operations  that  are 
done  through  the  abdomen.  The  chief  advantages  of  it 
are  that  it  carries  the  intestines  upward  out  of  the  pelvis 
and  allows  a  very  much  freer  view  of  the  pelvic  structures 
than  can  be  had  in  any  other  position. 

Operations  for  extrauterine  pregnancy,  large  ovarian 
cysts,  and  a  few  other  conditions  are  done  by  preference 
with  the  patient  in  the  dorsal  position  with  the  legs 
extended. 

Incision.  —  The  incision  is  made  in  the  abdominal  wall 
between  the  umbilicus  and  the  symphysis,  and  a  little  to 
one  side  or  the  other  of  the  median  line.  The  placing  of 
the  incision  to  one  side  of  the  median  line  is  done  in  order 
to  go  through  the  rectus  muscle.  Tension  upon  the  rectus 
muscle  when  the  wound  is  in  this  position  has  a  tendency 
to  close  and  not  to  cause  a  gaping  of  the  wound,  and  in 
this  way  helps  to  prevent  the  formation  of  a  post-operative 
hernia.  The  length  of  the  incision  depends  upon  the  thick- 
ness of  the  abdominal  wall,  the  size  of  the  growth  to  be 
removed,  or  the  character  of  the  work  to  be  done  in  the 
pelvis. 

The  first  incision  is  carried  through  the  skin  and  fat 
down  to  the  fascia  of  the  rectus  muscle.    When  the  bleed- 


ABDOMINAL    OPERATIONS  255 

ing  points  have  been  controlled  the  fascia  is  opened  and 
the  fibers  of  the  rectus  muscle  separated  by  blunt  dissec- 
tion. The  posterior  sheath  of  the  rectus  is  opened.  The 
peritoneum  is  then  picked  up  at  the  upper  end  of  the  wound 
(to  avoid  the  bladder)  by  two  dissecting  forceps  and  a 
small  cut  made  into  it.  If  the  patient  is  in  the  Trendel- 
enburg position,  air  will  rush  in  through  the  small  opening 
in  the  peritoneal  cavity  and  allow  the  peritoneum  to  be 
lifted  sufficiently  away  from  the  intestines  so  that  it  can  be 
incised  as  far  as  wished  without  danger  of  injuring  the 
intestines. 

Drainage.  —  It  is  not  possible  to  give  hard-and-fast  rules 
for  the  employment  of  drainage.  It  should  be  employed  in 
all  cases  where  there  has  been  free  pus  in  the  pelvis  of 
staphylococcus  or  streptococcus  origin.  These  will  ordi- 
narily include  all  cases  of  pelvic  infection  following  mis- 
carriages or  labor.  Where  there  has  been  an  injury  to  a 
ureter,  the  bladder,  or  the  intestine,  drainage  should  be 
used.  Many  gonococcus  infections,  other  conditions  in 
which  there  are  only  adhesions,  extrauterine  pregnancies, 
and  non-infected  cases  should  not  be  drained. 

The  most  satisfactory  route  for  drainage  is  through 
Douglas'  cul-de-sac  into  the  vagina.  This  drain  should  be 
inserted  from  above  downwards  and  can  be  introduced  by 
two  methods.  By  splitting  the  posterior  vaginal  wall  just 
below  the  cervix  from  the  abdominal  side,  the  end  of  the 
drain  can  be  pushed  out  into  the  vaginal  canal.  Another 
method  is  to  have  an  assistant  introduce  a  pair  of  long, 
heavy,  slightly  curved  forceps  into  the  vagina  and  push 
them  up  into  the  posterior  fornix  where  they  can  be  seen 
pouching  into  the  pelvis  beyond  the  cervix.  This  is  cut 
down  upon  and  the  forceps  allowed  to  penetrate  into  the 
pelvic  cavity.  The  forceps  are  then  opened  to  stretch  the 
opening  in  the  vaginal  wall  and  a  large  gauze  drain  is  then 


256  TECHNIQUE 

introduced  into  the  bite  of  the  forceps  from  the  pelvic  side 
and  the  forceps  are  withdrawn  carrying  the  gauze.  The 
end  of  the  gauze  is  left  projecting  into  the  vagina  and  the 
upper  portion  of  it  is  applied  to  the  parts  of  the  pelvis 
that  need  to  be  drained.  The  abdominal  wall  is  closed  over 
it  tightly. 

When  it  is  not  practical  to  drain  through  the  cul-de-sac 
the  drain  should  be  brought  out  through  the  lower  angle  of 
the  incision.  In  this  position  several  gauze  drains  covered 
with  rubber  protectors  are  very  satisfactory. 

The  drains  into  the  vagina  should  be  drawn  down  a 
couple  of  inches  at  the  end  of  forty-eight  hours,  and  after 
that  drawn  down  and  cut  off  a  little  every  second  or  third 
day  until  the  drain  is  completely  removed  at  the  end  of 
about  one  week.  The  drain  through  the  abdominal  wall 
should  be  loosened  up  in  two  or  three  days.  As  there  are 
usually  several  drains  put  in,  they  should  be  removed  one 
at  a  time. 

Closure  of  the  Abdominal  Wound.  —  A  stitch  of  number 
two  chromo sized  catgut  is  inserted  through  the  fascia  of 
the  rectus  muscle  and  through  the  muscla  and  the  perito- 
neum. The  end  of  the  suture  is  secured  by  forceps.  This 
suture  is  then  carried  by  a  cobbler's  stitch  back  and  forth 
through  the  edges  of  the  peritoneum  only,  until  it  is  entirely 
brought  together.  When  the  peritoneum  is  brought  to- 
gether in  this  way  the  cut  edges  of  it  are  turned  up  into 
the  wound  and  a  smooth  surface  is  obtained  on  the  under 
side  of  the  abdominal  wound.  When  the  last  stitch  is  put 
in  the  peritoneum  the  end  of  the  suture  which  is  still  free 
is  caught  with  forceps.  The  suture  is  tied  and  the  short 
end  is  then  cut  away,  leaving  a  double  thread,  which  is 
carried  up  through  the  muscle  and  through  the  fascia.  It 
is  then  carried  back  along  the  line  of  fascia  by  a  continuous 
stitch  in  such  a  manner  as  to  cause  the  edges  of  the  fascia 


ABDOMINAL    OPERATIONS 


257 


to  overlap.  This  brings  the  suture  back  to  the  point  of 
original  insertion,  where  it  is  tied  to  the  free  end  which  is 
held  by  the  first  pair  of  forceps.  Ordinarily  it  is  not  neces- 
sary to  put  any  stitches  in  the  fat  and  superficial  fascia, 
but  where  the  abdominal  wall  is  exceptionally  thick,  a  few 
interrupted,  loosely  tied  catgut  sutures  are  an  advantage. 
The  skin  is  closed  by  a  horse  hair  put  in  with  a  buttonhole 
stitch.  Where  very  much  tension  on  the  wound  is  feared 
the  catgut  stitches  can  be  reinforced 
by  a  few  figure-of-eight  silkworm-gut 
stitches  that  bring  together  all  of 
the  structures  except  the  peritoneum. 
These  figure-of-eight  stitches  must  be 
tied  very  loosely. 

Dressing  of  Wound.  —  The  wound 
is  dressed  by  putting  a  strip  of  gauze 
about  one  inch  wide  and  about  ten 
layers  thick  over  it.  A  short  strip  of 
adhesive  plaster  is  put  over  the  lower 
end  of  the  dressing,  and  strips  of  ad- 
hesive plaster  two  inches  wide,  and 
long  enough  to  extend  two-thirds  of 
the  circumference  of  the  body,  are 
put  on  overlapping  each  other  slightly 
until  the  entire  length  of  the  wound 
is  covered.  No  other  dressing  or  bandage  is  used.  A  nar- 
row dressing  allows  the  adhesive  plaster  to  become  at- 
tached to  the  skin  very  close  to  the  edges  of  the  wound, 
so  that  all  strains  from  coughing  or  other  movements 
of  the  patient  are  thrown  upon  the  adhesive  plaster  and 
not  upon  the  edges  of  the  wound  and  the  stitches  holding 
it  together.  The  patient  can  move  about  in  bed  without  dis- 
placing the  dressings.  Where  an  abdominal  drain  has  been 
put  in,  the  portion  of  the  wound  above  the  drain  is  closed 


Fig.  137.  —  Closure 
of  Abdominal  Wound. 


258  TECHNIQUE 

and  dressed  in  the  same  manner  as  if  there  had  been  no 
drain  put  in.  Over  the  drain  a  large  loose  gauze  dressing 
is  placed,  which  is  held  loosely  in  its  position  by  adhesive 


Fig.  138.  —  Deessing  of  Abdominal  Wound. 

plasters.  This  dressing  can  be  changed  at  any  time  or 
the  drains  removed  without  disturbing  the  dressing  on  the 
wound  above  the  point  of  drainage. 


VAGINAL   OPERATIONS 

Preparation.  —  The  preparations  for  vaginal  operations 
are  the  same  as  those  already  described  for  abdominal 
operations  in  regard  to  the  place  and  time  of  operation,  the 
instruments,  and  the  operator  and  assistants.  The  prepara- 
tion of  the  patient  involves  the  same  principles  as  the  prep- 
aration for  an  abdominal  operation.  The  bladder  and 
bowels  should  be  emptied.  The  pudendum  should  be  shaved. 
The  vulva  and  vagina  should  be  thoroughly  washed  with 


VAGINAL    OPERATIONS  259 

soap  and  water  and  then  with  one  to  two  thousand  bichloride 
of  mercury  solution. 

Posterior  Vaginal  Section.  —  Posterior  vaginal  section  is 
done  most  frequently  to  relieve  large  collections  of  pus  in 
the  pelvis,  more  particularly  the  pelvic  abscesses  that  fol- 
low miscarriages  and  labor.  These  are  usually  either  strep- 
tococcus or  staphylococcus  infections,  and  an  abdominal 
operation  for  an  active  infection  with  either  of  these  micro- 
organisms present  is  very  likely  to  be  disastrous.  Large 
hematoma;,  especially  if  they  are  infected,  and  some  few 
other  conditions  are  operated  upon  through  the  posterior 
vaginal  wall. 

Method  of  Operation.  —  The  perineum  is  retracted  by 
an  ordinary  Simon  or  Jackson  retractor  and  the  cervix  is 
grasped  by  a  bullet  forceps  and  drawn  upward  and  for- 
ward. A  long  incision  beginning  immediately  behind  the 
cervix  is  carried  downward  and  forward  in  the  median 
line  of  the  posterior  vaginal  wall.  When  operating  for  pus 
in  the  cellular  tissue  of  the  pelvis  after  the  vaginal  wall 
is  incised,  the  remainder  of  the  opening  is  made  by  blunt 
dissection. 

Anterior  Vaginal  Section.  —  The  peritoneal  cavity  is 
opened  through  the  anterior  vaginal  wall  for  the  removal 
of  small  tumors  of  the  ovary,  of  the  tube,  or  of  the  body 
of  the  uterus. 

Method  of  Operation.  —  The  perineum  is  retracted,  the 
cervix  is  drawn  downward,  and  a  transverse  incision  is 
made  through  the  mucous  membrane  of  the  vagina  just 
above  the  point  where  it  joins  the  cervix.  Another  incision 
is  carried  from  the  middle  of  this  line  upward  through 
the  anterior  vaginal  wall  toward  the  meatus  in  order  to 
get  all  the  room  necessary.  The  bladder  is  separated  from 
the  uterus ;  the  peritoneal  cavity  is  opened,  and  the  fundus 
of  the  uterus  is  drawn  downward  and  forward  through  this 


260  TECHNIQUE 

opening,  making  the  whole  of  the  body  of  the  uterus  and 
the  tubes  and  ovaries  easily  accessible. 

Dilatation  of  the  Cervix.  —  The  most  efficacious  method 
of  rapid  dilatation  of  the  cervix  is  with  some  form  of 
parallel-bar  dilators.  The  degree  of  dilatation  required 
varies  with  the  necessities  of  the  subsequent  operation. 
When  an  attempt  is  made  to  remove  a  growth  from  the 
interior  of  the  uterus,  or  when  the  dilatation  is  done  to 
overcome  a  congenital  narrowing  of  the  cervical  canal,  a 
very  wide  dilatation  is  called  for,  while  in  cases  in  which 
a  curettage  for  diagnosis  is  to  be  done,  it  is  only  necessary 
to  dilate  the  cervix  sufficiently  wide  to  introduce  a  proper 
curette.  There  are  great  differences  in  the  friability  of 
the  cervix,  and  care  should  be  taken  not  to  lacerate  it  by 
making  too  much  tension  upon  a  diseased  cervix,  or  by 
allowing  the  dilator  to  slip  down  so  that  the  tension  will 
come  on  the  external  os. 

Curettage.  —  The  edge  of  the  curette  should  be  sharp, 
and  it  should  be  so  made  that  this  edge  will  strike  the 
endometrium  at  right  angles,  so  that  the  effect  is  never 
to  cut  into  the  uterus  but  to  scrape  over  its  surface.  The 
end  of  the  curette  should  be  slightly  flattened  so  that  a 
surface  and  not  a  single  line  will  be  scraped  at  each  stroke 
of  the  curette.  For  incomplete  miscarriages  a  square- 
ended  curette  about  half  an  inch  wide  is  used.  In  attempt- 
ing to  remove  the  remains  after  a  partial  miscarriage,  it  is 
of  especial  importance  to  go  over  carefully  the  entire  an- 
terior wall  of  the  uterus.  In  curetting  for  carcinoma  of 
the  cervix  the  curette  should  be  carried  at  each  stroke  as 
nearly  down  to  healthy  tissue  as  possible.  This  lessens 
very  materially  the  hemorrhage.  A  sharp  curette  should 
be  used  and  one  that  is  large  enough,  so  that  the  whole 
field  may  be  gone  over  quickly. 

Before  curetting,  a  gauze  sponge  is  placed  in  the  vagina 


LOCAL    TREATMENT  2G1 

just  under  the  cervix,  and  all  material  scraped  out  of  the 
uterus  is  caught  on  this  sponge  and  afterwards  prepared 
and  examined  microscopically.  After  the  whole  endo- 
metrium has  been  thoroughly  gone  over  with  the  curette, 
the  cavity  of  the  uterus  is  wiped  out  with  two  strips  of 
gauze  saturated  with  a  weak  solution  of  bichloride.  It  is 
then  wiped  out  with  a  piece  of  dry  gauze.  No  packing  is 
left  in  the  uterus  except  to  control  excessive  bleeding  and  in 
cases  of  stenosis  of  the  cervix. 


LOCAL    TREATMENT 

Douches.  —  Vaginal  douches  are  given  for  their  cleansing 
effect  and  for  definite  therapeutic  purposes.  For  ordinary 
cleansing  the  most  satisfactory  douche  is  normal  salt  solu- 
tion. The  temperature  of  it  should  be  about  one  hundred 
degrees  F.,  and  about  two  quarts  is  the  quantity  ordinarily 
used.  To  exercise  a  definite  therapeutic  action  douches  of 
a  temperature  of  one  hundred  and  ten  to  one  hundred  and 
fifteen  degrees  are  used  in  inflammatory  conditions  in  the 
pelvis.  Either  plain  water  or  normal  salt  solution  can  be 
used.  The  patient  should  be  upon  her  back  with  the  hips 
slightly  elevated.  The  fountain  syringe  used  should  have 
a  free  flow,  so  that  a  large  volume  of  water  can  be  used 
under  low  pressure.  The  quantity  of  water  used  should  be 
from  one  to  two  gallons.  Douches  of  one  to  four  thousand 
bichloride  of  mercury  or  other  antiseptic  solutions  of  similar 
strength  are  used  in  infections  of  the  vagina.  All  antiseptic 
douches  should  be  followed  by  a  douche  of  plain  water  to 
remove  any  excess  of  the  antiseptic. 

In  the  late  stages  of  carcinoma  of  the  cervix,  or  other 
conditions  producing  offensive  odors,  weak  solutions  of  per- 
manganate of  potash  or  saturated  solutions  of  boracic  acid 
may  be  used  as  deodorants. 


262  TECHNIQUE 

Douches  of  large  volume  are  given  most  comfortably  on 
a  specially  constructed  douche  pan  which  has  a  rubber  tube 
which  drains  it  into  a  large  vessel  on  the  floor.  A  very 
satisfactory  arrangement  is  to  put  the  patient  crossways 
on  the  bed  with  the  hips  slightly  elevated,  letting  the  feet 
rest  on  two  chairs,  with  a  piece  of  rubber  cloth  under  the 
patient  arranged  so  that  it  will  drain  into  a  jar  on  the 
floor. 

Tampons.  —  The  tampon  most  frequently  used  is  made 
of  absorbent  cotton  or  specially  prepared  lambs'  wool. 
A  tampon  can  be  made  from  either  of  these  materials  by 
folding  it  up  lightly  so  as  to  make  an  apparently  large 
tampon  out  of  a  small  amount  of  material.  It  is  then  tied 
with  a  string  which  is  left  hanging  about  six  inches.  These 
tampons  can  be  used  for  either  dry  or  moist  applications. 
They  can  be  dusted  with  boracic  acid  or  other  mild  anti- 
septic powder  and  packed  into  the  vagina,  or,  as  is  most 
frequently  done,  they  can  be  saturated  with  pure  glycerin 
or  boroglyceride. 

The  glycerin  tampon  is  the  most  valuable  therapeutic 
agent  we  have  in  the  treatment  of  all  inflammatory  condi- 
tions of  the  pelvis  that  do  not  demand  an  operation.  The 
glycerin  tampon  is  left  in  position  about  twenty-four  hours. 
While  present  it  produces  a  profuse  watery  vaginal  dis- 
charge due  to  the  hygroscopic  action  of  the  glycerin.  It 
depletes  the  vessels  of  the  vagina,  relieves  pain,  and  pro- 
motes drainage  from  the  cervical  canal.  The  tampons  are 
ordinarily  renewed  every  second  or  third  day. 

In  cases  of  hemorrhage  due  to  incomplete  miscarriage 
or  to  fibroids  the  vagina  is  sometimes  packed  with  dry 
tampons  or  strips  of  sterile  gauze.  Tampons  of  this  sort 
should  not  be  allowed  to  remain  in  position  more  than 
twenty-four  hours. 

Applications.  —  The  use  of  Churchill 's  tincture  of  iodine, 


LOCAL   TREATMENT  263 

nitrate  of  silver,  and  carbolic  acid  in  the  treatment  of 
diseases  of  the  vulva,  vagina,  and  cervix  has  been  men- 
tioned in  connection  with  the  special  diseases.  Local  appli- 
cations to  the  uterine  canal  above  the  internal  os  are  not 
recommended  for  any  condition.  The  benefit  to  be  derived 
from  them  is  always  doubtful  and  the  danger  of  carrying 
infection  to  the  tubes  in  attempts  to  use  them  is  great. 


CHAPTER   XXI 

POST-OPEEATIVE    COMPLICATIONS 

Shock.  —  Extreme  degrees  of  shock  after  gynecological 
operations  are,  fortunately,  rare.  To  lessen  the  ordinary 
degree  of  shock,  the  bed  in  which  the  patient  is  put  after 
operation  should  be  well  warmed;  but  it  is  not  necessary 
ordinarily  to  pack  the  patient  with  hot  bottles  and  hot 
packs,  as  there  is  usually  more  danger  of  burning  the 
patient  than  there  is  of  doing  her  any  good. 

Extreme  degrees  of  shock  are  recognized  by  a  weak, 
rapid  pulse;  extreme  pallor;  excessive  perspiration;  and 
shallow  respiration.  The  symptoms  come  on  promptly 
either  during  or  immediately  after  the  conclusion  of  an 
operation.  The  patient's  head  should  be  lowered,  the  limbs 
elevated,  and  normal  salt  solution  should  be  given  under  the 
breasts.  A  rectal  injection  of  hot  salt  solution  acts  more 
slowly  than  the  salt  solution  by  hypodermoclysis,  but  is  very 
useful.  Some  benefit  is  derived  from  strychnia  in  moderate 
doses,  but  the  most  reliable  agents  are  the  position,  heat, 
and  salt  solution. 

Hemorrhage.  —  Post-operative  hemorrhage  is  usually 
due  to  the  slipping  of  a  ligature.  To  avoid  this  accident 
large  masses  of  tissue  should  never  be  included  within  a 
ligature.  Large  vessels  like  the  ovarian  and  uterine  are 
tied  with  number  three  chromosized  catgut.  The  ligature 
should  be  tied  first  with  a  surgical  knot  followed  by  two 
ordinary  knots.     The  ends  of  the  ligature  should  not  be 

264 


INFECTION    OF    ABDOMINAL  WOUND  265 

cut  too  close  to  the  knot.  The  signs  of  hemorrhage  can 
usually  be  distinguished  from  those  of  shock.  The  symp- 
toms appear  a  few  hours  after  the  conclusion  of  the  opera- 
tion instead  of  immediately  as  they  do  in  shock.  The 
pulse  is  weak  and  usually  rapid,  but  it  may  be  slow.  The 
patient  becomes  very  pale  and  there  is  gasping  respiration 
indicating  air  hunger.  There  is  a  fall  in  the  body  tempera- 
ture. These  symptoms,  except  in  cases  of  sudden  and  severe 
hemorrhages,  are  not  marked  in  the  beginning  but  gradu- 
ally increase  in  intensity.  It  is  very  important  that  post- 
operative hemorrhages  should  be  recognized  promptly,  be- 
cause the  only  treatment  is  to  reopen  the  abdomen  and 
secure  the  bleeding  vessels. 

Vomiting.  —  For  repeated  vomiting  the  most  satisfactory 
treatment  is  stomach  lavage.  Some  patients  without  hav- 
ing marked  vomiting  have  nausea  with  a  great  deal  of  pain 
and  distention  of  the  stomach.  This  is  very  frequently  due 
to  the  presence  of  an  excessive  quantity  of  mucus  or  bile 
in  the  stomach.  The  relief  obtained  by  washing  out  the 
stomach  is  immediate. 

Distended  Intestines.  —  The  distention  of  the  intestines 
by  gas  after  operation  is  a  source  of  much  discomfort  to 
the  patient.  If  the  intestines  are  not  allowed  to  be  exposed 
to  the  air  during  the  operation,  they  are  very  much  less 
likely  to  become  distended  with  gas  afterwards.  As  a  pro- 
phylactic during  all  pelvic  operations,  as  soon  as  the  abdo- 
men is  opened  the  intestines  and  omentum  should  be  pushed 
well  above  the  line  of  incision  and  kept  there  by  abdominal 
packs.  The  upright  position  after  operation  also  diminishes 
the  number  of  cases  where  distention  of  the  intestine  gives 
trouble.  When  distention  of  the  intestines  does  occur,  much 
relief  can  be  obtained  by  an  ordinary  soap  and  water  enema, 
or  an  enema  containing  half  an  ounce  of  turpentine. 

Infection  of  the  Abdominal  Wound.  —  The   abdominal 


266  POST-OPERATIVE    COMPLICATIONS 

wound  may  be  infected  by  allowing  it  to  come  in  contact 
with  infected  tissues  removed  from  the  abdomen.  This  may 
occur  even  where  the  peritoneum  does  not  become  infected. 
It  usually  manifests  itself  a  few  days  after  the  operation. 
There  is  pain  in  the  neighborhood  of  the  wound  and  there 
may  be  swelling  and  rise  of  temperature.  Where  the  abdo- 
men has  been  closed  up  with  an  absorbable  suture  material 
the  infection  promptly  subsides  after  drainage  is  estab- 
lished. If  the  abdominal  wall  has  been  closed  up  with  non- 
absorbable suture  material  the  infection  will  not  subside 
until  after  the  sutures  have  been  removed. 

Stitch  infections  of  the  skin  are  usually  due  to  the  fail- 
ure to  properly  cleanse  the  skin  before  operation.  The 
stitches  should  be  promptly  removed  and  proper  drainage 
established. 

A  post-operative  sinus  through  the  abdominal  wall  into 
the  pelvic  cavity  is  usually  due  to  an  infection  around  a 
ligature,  or  it  may  be  from  an  infected  Fallopian  tube  that 
has  not  been  removed.  A  sinus  of  this  character  will  re- 
main until  the  offending  foreign  body  is  removed. 

Fecal  Fistulse.  —  Fecal  nstulse  occurring  after  either  ab- 
dominal or  vaginal  operations  are  due  to  the  injury  that 
has  been  done  the  wall  of  the  intestine  by  the  inflammatory 
process  which  called  for  operation.  Nearly  all  of  these 
fecal  fistulae  will  close  of  their  own  accord.  Where  they 
have  failed  to  close  within  a  year,  they  should  be  opened 
up  and  the  defect  in  the  intestine  repaired. 

Hernia.  —  Post-operative  hernise  occur  very  frequently 
after  drainage  cases,  but  when  the  abdominal  wound  has 
been  properly  and  completely  closed,  hernise  are  very  rare. 

Repair  of  Post-operative  Hernia.  —  The  scar  and  skin 
over  the  hernia  are  dissected  entirely  away.  The  sac  of 
the  hernia  is  opened  and  the  contents  separated  from  it  and 
returned  to  the  abdominal  cavity.    Excess  tissue  in  the  sac 


heknia  '•;; 

should  be  cut  away.  The  peritoneum  is  then  brought  to- 
gether as  in  any  other  abdominal  wound.  An  incision  is 
made  into  the  fascia  on  each  side  exposing  the  rectus 
muscle.  The  posterior  layer  of  the  fascia  is  then  united  by 
continuous  suture  below  the  muscle,  and  the  fascia  over 
the  muscle  is  united  by  another  continuous  suture.  It  is 
usually  best  to  reinforce  these  sutures  with  a  few  figure- 
of-eight  silkworm-gut  stitches.  The  skin  wound  is  united 
in  the  ordinary  way. 


CHAPTER   XXII 

POST-OPERATIVE   TREATMENT 

ABDOMINAL   OPERATIONS 

Position  of  Patient.  —  After  all  abdominal  operations,  as 
soon  as  there  is  partial  recovery  from  the  anesthetic  the 
patient  should  be  placed  in  the  upright  position.  When  this 
is  done  the  complete  recovery  from  the  anesthetic  is  prompt 
and  the  nausea  and  vomiting  are  decreased ;  the  intestines 
resume  promptly  their  proper  relation  to  each  other  and 
there  is  much  less  tendency  for  the  stomach  and  intestines 
to  become  distended  with  gas;  all  blood  and  exudate  re- 
salting  from  irritation  of  the  peritoneum  gravitates 
promptly  to  the  pelvis,  where  it  produces  less  disturbance 
than  it  does  in  the  upper  abdomen.  The  exceptions  to 
this  rule  should  be  patients  who  have  lost  a  large  quantity 
of  blood,  or  when  from  other  causes  the  condition  of  the 
heart  contraindicates  the  upright  position.  Under  ordi- 
nary circumstances  it  is  not  necessary  for  the  patient 
to  maintain  this  upright  position  more  than  a  few  hours. 
After  that  she  should  assume  the  position  which  is  most 
comfortable  to  her. 

All  drainage  cases  should  be  kept  in  the  upright  position 
for  forty-eight  hours.  At  the  end  of  that  time  protective 
adhesions  are  formed  shutting  off  the  field  of  operation 
from  the  remainder  of  the  abdomen  so  that  the  position 
of  the  patient  becomes  of  less  importance.    So  long  as  the 

268 


ABDOMINAL    OPERATIONS  269 

drain  is  in  position  the  patient  should  sit  up  for  a  part 
of  each  day. 

Diet.  —  After  the  patient  has  recovered  consciousness 
from  the  anesthetic  she  may  be  given  a  tablespoonful  of  hot 
water  every  two  hours.  If  vomiting  occurs  the  water  should 
be  suspended  for  from  four  to  six  hours,  after  which  time  it 
can  be  resumed.  If  the  water  is  well  borne  it  may  be  given 
in  slightly  increasing  quantities.  If  there  is  severe  pain 
during  the  first  twenty-four  hours  after  operation,  morphia 
in  small  doses  hypodermically  should  be  given  to  relieve  it. 
It  is  best  to  begin  with  a  dose  of  one-eighth  to  one-sixth  of 
a  grain,  which  can  be  repeated  if  absolutely  necessary.  The 
object  is  to  get  along  with  the  smallest  possible  quantity 
that  will  make  the  patient  comfortable.  No  morphia  should 
be  given  after  the  first  twenty-four  hours  except  under 
extraordinary  indications.  During  the  second  twenty-four 
hours  the  amount  of  fluid  can  be  increased,  and  if  there 
is  no  disturbance  of  the  stomach,  small  quantities  of  clear 
broth  or  small  quantities  of  well-diluted  albumen  can  be 
given.  Milk  is  usually  not  well  borne  and  should  be  avoided. 
The  liquid  foods  can  usually  be  increased  in  quantity  during 
the  third  twenty-four  hour  period. 

Beginning  forty-eight  hours  after  the  operation  the  pa- 
tient is  given  one-tenth  grain  of  calomel  every  half  hour 
until  one  grain  is  taken.  Early  the  next  morning  two 
drams  of  sulphate  of  magnesia  are  given,  and  if  the  bowels 
do  not  move  promptly  a  soap  and  water  enema  is  given. 
After  the  bowels  have  moved,  the  patient  is  put  on  a  semi- 
solid diet  and  then  promptly  on  a  regular  diet. 

Removal  of  Stitches.  —  On  the  eighth  day  the  adhesive 
plasters  are  cut  from  below  upward  directly  over  the  wound 
and  turned  back  exposing  the  dressing.  The  dressing  is 
removed  and  the  stitches  taken  out.  A  narrow  strip  of 
dry  gauze  is  then  laid  over  the  wound  and  the  cut  ends 


270  POST-OPEEATIVE    TREATMENT 

of  the  adhesive  plasters  are  overlapped  and  secured  with 
safety  pins.  The  adhesive  plasters  will  usually  remain  in 
position  until  time  for  the  patient  to  get  out  of  bed,  and 
by  that  time  they  are  usually  loosened  sufficiently  to  come 
off  easily.  "When  they  have  become  loosened  of  their  own 
accord  they  are  entirely  removed  and  a  few  long  strips  of 
fresh  plaster  are  applied.  These  strips  of  plaster  are  al- 
lowed to  remain  on  until  they  come  off  of  their  own  accord. 
This  is  usually  four  or  five  weeks  after  the  operation,  and 
after  that  time  no  further  support  is  needed. 

Time  in  Bed.  —  The  patient  should  be  kept  in  bed  from 
eight  to  fourteen  days,  the  time  depending  on  the  char- 
acter of  the  operation  and  the  general  condition  of  the 
patient. 

VAGINAL   OPERATIONS 

Repair  of  the  Vaginal  Outlet.  —  One  of  the  requisites  of 
good  results  after  operations  on  the  vaginal  outlet  is  to 
interfere  as  little  as  possible  with  the  wound.  A  sterile  pad 
is  usually  placed  over  the  perineum,  but  it  probably  does 
as  much  harm  as  good.  The  perineum  should  be  irrigated 
sufficiently  often  to  keep  it  clean,  but  it  should  not  be 
sponged  or  rubbed  with  a  cloth.  The  patient  should  be 
given  sufficient  doses  of  magnesium  sulphate  to  cause  the 
bowels  to  move  loosely  every  day.  After  operations  for 
complete  tears  of  the  perineum  it  is  of  special  importance 
to  keep  the  bowel  movements  soft  to  prevent  the  stitches 
from  being  torn  out  by  the  expulsion  of  hard  fecal  masses. 
The  patient  should  be  allowed  to  void  urine  herself,  because 
some  normal  urine  flowing  over  the  wound  will  do  less  harm 
than  repeated  catheterization.  Vaginal  douches  should  not 
be  used  until  union  has  taken  place.  The  patient  should 
remain  in  bed  about  two  weeks,  but  there  is  no  occasion 


VAGINAL    OPEKATIONS  271 

to  bandage  the  legs  together  or  to  keep  the  patient  in  any 
fixed  position.  The  only  object  to  be  gained  by  the  recum- 
bent posture  is  to  remove  as  far  as  possible  all  strain  from 
the  pelvic  floor  during  the  healing  process. 

Non-absorbable  sutures  that  have  been  passed  through 
the  skin  should  be  removed  on  the  eighth  day.  No  attempt 
should  be  made  to  remove  non-absorbable  sutures  that  have 
been  placed  above  the  vaginal  outlet  until  at  least  three 
weeks  after  the  operation.  They  produce  little  or  no  irri- 
tation, and  can  be  allowed  to  remain  until  union  is  so  firm 
that  the  vaginal  outlet  will  bear  a  moderate  amount  of 
stretching. 

As  soon  as  these  patients  have  recovered  from  the  anes- 
thetic they  should  be  put  at  once  on  a  liberal  diet. 

Curettement.  —  After  an  ordinary  curettement  the  patient 
is  usually  kept  in  bed  from  three  to  five  days.  After  the 
first  day  a  vaginal  douche  of  hot  normal  salt  solution  is 
usually  given  twice  daily. 

Vaginal  Celiotomy.  —  The  general  after-treatment  of  pa- 
tients who  have  had  vaginal  celiotomies  done  is  the  same  as 
that  following  abdominal  operations;  except  that  having 
nothing  to  fear  from  possible  ventral  herniae  they  are  able 
to  leave  the  bed  earlier. 


INDEX 


INDEX 


Abdomen,    enlargement    of,    due    to 
ascites,  237. 

to  distended  bladder,  238. 

to  distended  intestines,  237. 

to  fat  abdominal  wall,  237. 

to  fibroids,  236. 

to  ovarian  cysts,  233,  234. 

to  pregnancy,  236. 

to  tuberculous  peritonitis,  encysted, 
238. 

to  twisted  pedicle  of  ovarian  cyst, 
239. 
Abdominal  examination,  3. 
Abdominal  hysterectomy  for  carcinoma, 
159. 

for  fibroids,  183. 

for  infection,  203. 
Abdominal  myomectomy,  186. 
Abdominal  operation  for  extrauterine 

pregnancy,  216. 
Abdominal  pregnancy,  213. 
Abdominal  wound,  closure  of,  256. 

dressing  of,  257. 

infection  of,  post-operative,  265. 
Abortions  due  to  lacerated  cervix,  121. 
Abscess,    infected    extrauterine    preg- 
nancy a  cause  of,  214. 

pelvic,  208. 

secondary  to  hematoma  of  vulva,  28. 

suburethral,  81. 

tubo-ovarian,  193. 

vulvo-vaginal  gland,  35. 
Adeno-carcinoma  of  cervix,  147. 

of  uterus,  149. 
Adenoma,  140. 

differentiated  from  adeno-carcinoma, 
140. 
Adeno-fibromyoma.    See  Fibroids. 


Adhesions,     cause     of     retrodisplace- 
ments,  102. 

of  ovarian  cysts,  239. 
After  treatment  in  abdominal  opera- 
tions, 268. 

in  vaginal  operations,  270. 
Alexander's     operation     for.    retrodis- 

placement  of  uterus,  110. 
Alum  in  gonorrheal  vaginitis,  40. 

in  pruritus  vulvae,  25. 
Amenorrhea,  14. 

causes  of,  14. 

emmenagogues  in,  15. 

primary,  14. 

secondary,  14. 
Amenorrhea  due  to  absence  of  ovaries, 
14. 

to  anemia,  14. 

to  change  of  climate,  14. 

to  lactation,  15. 

to  pregnancy,  15. 

to  tuberculosis,  general,  139. 
Anesthesia,  6,  8,  36,  254. 
Anesthetic  in  urethral  caruncle,  77. 

in  vaginismus,  47. 
Anteflexion  of  uterus,  99. 
Anterior  vaginal  section,  technique  of, 

259. 
Anteversion  of  uterus,  99. 
Antiseptic  solutions  in  urethritis,  80. 
Antitoxin,  diphtheritic,  23. 
Appendix,  location  of,  4. 
Applications,  262. 
Arteries,  ovarian,  96. 

uterine,  96. 
Ascites,  differential  diagnosis  of,  from 
ovarian  cyst,  237. 

due  to  ovarian  papilloma,  234,  246. 


275 


2  re 


INDEX 


Atresia  of  cervix,  131,  148. 

of  hymen,  36. 

of  vagina,  44. 
Auscultation  in  examination,  5. 

Bacillus  of  Doederlein,  39. 
Bacillus,  Klebs-Loefler,  23,  41. 
Bacillus  tuberculosis,  42. 
Backache  due  to  injury  to  pelvic  floor, 
50. 

to  lacerated  cervix,  121. 

to  laceration  of  perineum,  50. 

to  prolapse  of  uterus,  113. 

to  retrodisplacement,  103. 

to  subinvolution,  166. 
Bacteria,  cause  of  endometritis,  134. 
Bartholin's  glands,  20. 
Benzoic  acid  in  cystitis,  87. 
Bimanual  examination,  6. 
Bismuth  subnitrate  in  pruritus  vulvae, 
25. 

in  venereal  warts,  34. 
Bladder,  capacity  of,  reduced,  86. 

dilatation  of,  87. 

diseases  of,  76. 

distended,  differential  diagnosis  of, 
from  ovarian  cyst,  238. 

exstrophy  of,  84. 

hypertrophy  of,  86. 

inflammation  of,  85. 

irrigation  of,  in  cystitis,  87. 
Blood,  examination  of,  9. 
Blood-vessels,  enlarged,  171. 
Boracic  acid  in  vaginitis,  41. 
Breasts  during  menses,  11. 
Broad  ligament  tumors,  249. 
Bromides  in  pruritus  vulvae,  25. 

Cachexia,  153. 
Calculus,  vesical,  88. 
Calomel  in  pruritus  vulvae,  25. 

in  venereal  warts,  34. 
Carbolic  acid  in  chancroid,  27. 

in  pruritus  vulvae,  25. 
Carcinoma     associated    with    uterine 
fibroids,  175. 

in  ovarian  cysts,  241. 

of  Fallopian  tube,  207. 


Carcinoma  of  ovaries,  246. 

of  uterus.  See  Uterus,  Carcinoma  of. 

of  vagina,  46.  • 

of  vulva,  29. 
Caruncle,  urethral,  76. 
Catheter,  7. 
Cautery  in  carcinoma  of  uterus,  155. 

in  urethral  caruncle,  77. 

in  venereal  warts,  34. 
Celiotomy,      vaginal,      post-operative 

treatment,  271. 
Cellulitis,  pelvic.    See  Pelvic  Cellulitis. 
Cervix  uteri,  94. 

adeno-carcinoma  of,  147. 

amputation  of,  124,  125,  132,  156. 

atresia  of,  131. 

carcinoma  of,  143. 
course  of,  151. 
squamous  cell,  143. 

cystic  degeneration  of,  129. 

dilatation  of,  technique  of,  260. 

elongation  of,  132. 

epithelioma  of,  143. 
basal  cell,  146. 
cauliflower  growth,  143. 
schirrus,  147. 
varieties  of,  146. 

erosion  of,  128. 

hypertrophy  of,  132. 

laceration  of,  120. 

associated  lesions  of,  120. 

mucous  membrane  of,  94. 

stenosis  of,  130. 

ulcer  of,  154. 
Chancre,  26. 
Chancroid,  26. 

Chill  due  to  pelvic  cellulitis,  208. 
Chorio-epithelioma,  163. 

of  vagina,  46. 
Chorionic  villi,  164. 

in  tube,  211. 
Cicatrices  in  vault  of  vagina,  116. 
Clinical  record,  1. 
Clitoris,  19. 
Cocaine  in  pruritus  vulvae,  25. 

in  vaginismus,  47. 
Coition,  painful,  causes  of,  47. 
due  to  prolapsed  ovaries,  225. 


INDEX 


•j;; 


Compress,  use  of,  in  hematoma,  28. 
Condylomata,  syphilitic,  33. 
Constipation  due  to  fibroids,  179. 

to  parovarian  cysts,  248. 

to  prolapse  of  uterus,  113. 

to  retrodisplacements,  103. 
Cord,  traction  on,  as  cause  of  inver- 
sion of  uterus,  117. 
Corpus  ablicans,  219. 
Corpus  luteum,  218. 
Curettage,  for  adenoma,  141. 

for  carcinoma  of  uterus,  155. 

for  endometritis,  139. 

for  fibroids,  182. 

for  hypertrophic  endometrium,  140. 

for  subinvolution,  167. 

post-operative  treatment  of,  271. 

technique  of,  260. 
Curette,  8. 
Cystitis,  bacteria  in,  85,  86. 

due  to  catheter,  85. 
to  cystocele,  62,  85. 
to  foreign  bodies,  85. 
to  infection  from  kidney,  86. 
to  salpingitis,  86. 

secondary  to  vesico-vaginal  fistula, 
70. 
to  urethritis,  85. 
Cystocele,  62,  102. 
Cystoscope,  9. 

Cystic  ovaries.    See  Ovaries,  Cystic. 
Cysts,  occlusion,  of  vagina,  45. 

of  Gartner's  duct,  45. 

of  vagina,  45. 

ovarian.    See  Ovarian  Cysts. 

parovarian,  248. 

Decidual  cells  in  tube,  211. 

Deciduoma  malignum,  163. 

Defecation,    painful,    due    to    pelvic 
cellulitis,  208. 
to  prolapsed  ovaries,  225. 

Dermoid  cysts,  231. 

Diet,  post-operative,  268. 

Dilatation,    forcible,   cause   of   lacera- 
tion of  cervix,  120. 

Diphtheritic     vulvitis,     antitoxin     in, 
23. 


Distended     intestines,     differentiated 

from  ovarian  cysts,  237. 
post-operation,  265. 
Doederlein,  acid  secreting  bacillus  of,  39. 
Dorsal  positions,  9. 
Douches,  vaginal,  261. 

in  carcinoma,  155. 

in  endocervicitis,  127. 

in  follicular  vaginitis,  41. 

in  gonorrheal  vaginitis,  40. 

in  lacerated  cervix,  122. 

in  pruritus  vulvae,  25. 

in  salpingitis,  198. 

in  subinvolution,  167. 

in  vaginitis  of  children,  43. 

in  vulvitis,  21. 
Drain,  removal  of,  201. 
Drainage,  after  abdominal  operations, 

255. 
for  pelvic  cellulitis,  209. 
in  phlegmonous  vulvitis,  23. 
Ducrey,  strepto-bacillus  of,  26. 
Ducts  of  Miiller,  96. 
Dysmenorrhea,  17. 

due  to  anteflexion,  17,  100. 

to  cirrhosis  of  ovaries,  224. 

to  cystic  ovaries,  222. 

to  fibroids,  179. 

to  hematoma  of  ovaries,  223. 

to  ovarian  cysts,  233. 

to  prolapsed  ovaries,  17,  225. 

to  retrodisplacements,  17,  103. 

to  salpingitis,  17,  195. 

to  stenosis  of  cervix,  17,  131. 

to  superinvolution,  167. 
membranous,  18. 
Dysparunia,  47. 

Ectopic    gestation.      See   Extrauterine 

Pregnancy. 
Electricity,  treatment  of    fibroids  by, 

181. 
Elephantiasis,  30. 
Emmenagogues,  15. 
Emmet's  operation  for  laceration  of  the 

perineum,  56. 
Endocervicitis,  126. 
Endometritis,  134. 


218 


IXDEX 


Endometritis,  cervical,  126. 

tuberculous,  139. 
Endometrium,  histology,  of,  91. 

hypertrophic,  102,  139,  210. 

infections  of,  134. 

loss  of  epithelium  of,  12. 

of  extrauterine  pregnancy,  210. 

post-menstrual,  92. 

pre-menstrual,  92. 
Epithelioma  of  cervix.     See  Cervix. 

of  vulva,  29. 
Erosion  of  cervix,  128. 
Examination  of  patient,  1. 

abdominal,  3. 

vaginal,  5. 
bimanual,  6. 
Exstrophy  of  bladder,  84. 
Extrauterine  pregnancy,  210. 

diagnosis  of,  215. 

menstrual  history  in,  215. 

pathology  of,  210. 

rupture  in,  212. 
cause  of,  211. 

symptoms  of,  214. 

treatment  of,  216. 

tubal  abortion  in,  213. 

Fallopian  tubes,  anatomy  of,  188. 

atrophy  of,  after  menopause,  13. 

carcinoma  of,  207. 

fibromyoma  of,  207. 

inflammation  of.    See  Salpingitis. 

papilloma  of,  207. 

sarcoma  of,  207. 

tumors  of,  207. 
Falls,  as  cause  of  retrodisplacements, 

102. 
Fascia  of  levator  ani,  48. 
Fat  abdominal  wall,  differentiation  of, 

from  ovarian  cysts,  237. 
Fecal  fistula,  266. 
Feces,  incontinence  of,  51. 
Fever  due  to  pelvic  cellulitis,  208. 

to  salpingitis,  196. 
Fibroblasts,  135. 
Fibroids  of  Fallopian  tube,  207. 

of  vagina,  46. 

of  vulva,  32. 


Fibroids,  ovarian,  245. 
uterine,  168. 

blood  supply  to,  170. 
calcareous  degeneration  of,  174. 
capsule  of,  170. 
carcinoma  with,  175. 
cause  of  endometritis,  134. 

of  retrodisplacements,  102. 
cervical,  169. 

cystic  degeneration  of,  174. 
diagnosis  of,  179. 
differential     diagnosis     of,     from 
ovarian  cyst,  236. 
from  pregnancy,  181. 
fatty  degeneration  of,  173. 
hyaline  degeneration  of,  173. 
indications  for  operation  in,  182. 
interligamentous,  169. 
interstitial,  169. 

microscopical  appearance  of,  172. 
migration  of,  170. 
necrosis  of,  174. 
number  of,  177. 
origin  of,  170. 
period  of  growth  of,  176. 
rate  of  growth  of,  176. 
relation  of,  to  pregnancy,  178. 
sarcoma  in,  174. 
size  of,  177. 
submucous,  169. 

cause  of  inversion  of  uterus,  117. 
subperitoneal,  169. 
treatment  of,  181. 
Fibromyoma.    See  Fibroids. 
Filaria  sanguinis  hominis,  31. 
Fissure,  vesico-urethral,  84. 
Fistula,  fecal,  266. 
recto-vaginal,  66. 
ure thro-vaginal,  69. 
uretero-vaginal,  73. 
urinary,  68. 

vesico-utero-vaginal,  72. 
vesico-uterine,  72. 
vesico-vaginal,  70. 
Flap-splitting  operation    for    retrodis- 
placements of  uterus,  54. 
Forceps,  bullet,  8. 
dressing,  8. 


IXDEX 


379 


Gall  bladder,  4. 
Gartner's  duct,  248. 

vaginal  cysts  in,  45,  248. 
Gas  bacillus,  cause  of  vaginitis,  41. 
Gilliam's  operation  for  retrodisplace- 

ment  of  uterus,  109. 
Glands,  destruction  of,  135. 

dilated,  136. 

inguinal,  26,  27,  29. 

pelvic,  96. 

carcinoma  in,  159. 
Gonococci,  21. 

in  vaginal  discharge,  40. 

in  vaginitis  in  children,  43. 

in  vulvo-vaginal  glands,  35. 
Graafian  follicles,  218. 

Hegar's  operation,  58. 
Hematoma  of  vulva,  28. 
Hematometria  due  to  atresia  of  cervix, 

31. 
Hemorrhage,  after  menopause,  153. 
due  to  extrauterine  pregnancy,  214. 
to  laceration  of  cervix,  121. 
to  prolapse  of  uterus,  113. 
to  ruptured  ovarian  cyst,  241. 
to  ruptured  varicocele,  27. 
into  ovarian  cyst,  228,  238. 
post-operative,  264. 
post-partum,    due   to   varicocele   of 

broad  ligament,  250. 
uterine.    See  Uterine  Hemorrhage. 
Hernia,  inguinal,  31. 
post-operative,  266. 
repair  of,  266. 
History,  1. 

Hot   applications   in    gonorrheal   vul- 
vitis, 21. 
in  pelvic  cellulitis,  209. 
in  phlegmonous  vulvitis,  23. 
Hydrocele,  31. 
Hydrosalpinx,  192. 
Hymen,  imperforate,  36. 

absence  of  menstrual  flow  in,  36. 
Hyperesthesia  of  vulva,  25. 
Hypertrophic  endometrium,  139. 
Hypertrophy  of  cervix,  132. 
of  ovaries,  224. 


Hysterectomy,     abdominal,     for     car- 
cinoma, 159. 
for  fibroids,  183. 
for  salpingitis,  203. 
for  tuberculous  salpingitis,  207. 
vaginal,  157. 

Indigestion  due  to  retrodisplaccments, 
103. 

Infection,   contra-indication   for  myo- 
mectomy, 178. 

Inguinal  hernia,  31. 

Injuries,  cause  of  stenosis  of  vagina,  44. 
to  pelvic  floor,  102. 

cause  of  retrodisplaccments,  102. 
to  vulva,  34. 

Inspection,  abdominal,  3. 
vaginal,  5. 

Instruments  used  in  examination,  6. 

Intermenstrual  pain,  225. 

Intestines,  distended,  237. 

Intrauterine  stem,  132. 

Inversion  of  uterus,  117. 

Iodine  in  endocervicitis,  127. 
in  lacerated  cervix,  122. 

Itching  of  vulva,  24. 

Klebs-Loeffler  bacillus,  23,  41. 
Knee-chest  position,  10. 
Kraurosis,  27. 

Labia  majora,  19. 

adhesions  of,  20. 

skin  infections  of,  20. 
Labia  minora,  19. 
Laceration  of  cervix,  120. 
Lead  acetate  in  pruritus  vulva*,  25. 
Leucorrhea  due  to  endometritis,  138. 

to  erosion  of  cervix,  128. 

to  fibroids,  179. 

to  lacerated  cervix,  121. 

to  mucous  polypi,  129. 

to  retrodisplacement  of  uterus,  104. 

to  salpingitis,  196. 

to  subinvolution,  166. 

to  tuberculous  endometritis,  139. 
Levator  ani,  38,  49. 
Ligaments  of  uterus,  98. 


280 


INDEX 


Lithopedian,  213. 
Lithotomy  position,  9. 
Local  treatment  in  gynecological  com- 
plaints, 261. 
Lymphatics  of  uterus,  96. 

Medical  treatment  of  fibroids,  181. 
Menopause,  13. 

age  of  occurrence  of,  13. 
anatomical  changes  after,  13. 
hemorrhage  after,  13. 
nervous  phenomena  of,  13. 
Menorrhagia,  15. 
causes  of,  15. 
due  to  cystic  ovaries,  222. 
to  endometritis,  138. 
to  ovarian  cyst,  233. 
to  prolapse,  113. 
to  retrodisplacements,  104. 
to  subinvolution,  166. 
to  varicocele  of  broad  ligament, 
250. 
Menstruation,  11. 

beginning  of,  age  of,  11. 
breasts  during,  11. 
cessation  of,  13. 

age  of,  13. 
composition  of  flow  in,  11. 
delayed,  12. 
duration  of,  11. 
endometrium  after,  92. 
endometrium  before,  92. 
follicular  vaginitis  after,  40. 
normal,  11. 

ovarian  secretion  in,  cause  of,  12. 
precocious,  12. 
relation  of  ovulation  to,  12. 
scanty,  due  to  cirrhosis  of  ovaries, 
224. 
to  cystic  ovaries,  222. 
to  superinvolution,  167. 
vicarious,  12. 
Mercury  bichloride  in  aphthous  vagi- 
nitis, 41. 
in  gonorrheal  vaginitis,  40. 
in  pruritus  vulvae,  25. 
in  vaginitis  of  children,  43. 
Metritis,  102. 


Metrorrhagia,  15. 

causes  of,  15. 
Micturition,  frequent.     See  Urination, 
Frequent. 

painful.    See  Urination,  Painful. 
Miscarriage,  18. 
Morphia  in  carcinoma,  155. 

in  pelvic  cellulitis,  209. 
Mucous  polypi,  128. 
Myoma.    See  Fibroids. 
Myomectomy,  abdominal,  186. 

vaginal,  182. 

Nabothian  follicles,  126,  128. 
Nausea  due  to  prolapsed  ovaries,  225. 
Nervous  symptoms  due  to  cirrhosis  of 
ovaries,  224. 

to  laceration  of  cervix,  121. 

to  prolapsed  ovaries,  225. 

to  retrodisplacements  of  uterus,  104. 

to  urethral  caruncle,  76. 
Nitric  acid  in  chancroid,  27. 

Obesity,  14. 

Obstetric  forceps,  cause  of  laceration 

of  cervix,  120. 
Occipital  headache  due  to  prolapsed 
ovaries,  225. 

to  retrodisplacements  of  uterus,  103. 
Odium  albicans  in  aphthous  vaginitis, 

41. 
Oophoritis,  221. 

chronic,  222. 
Operation  for  anteflexion,  101. 

for  cystocele,  63. 

for  extrauterine  pregnancy,  216. 
vaginal,  217. 
with  dead  fetus,  217. 
with  living  fetus,  217. 

for  laceration  of  cervix,  122. 

for  ovarian  cysts,  242. 
during  pregnancy,  244. 

for  parovarian  cysts,  249. 

for  salpingitis,  202. 

for  vesico-vaginal  fistula,  71. 
Operations : 

Alexander's,  110. 

Emmet's,  56. 


INDEX 


281 


Operations : 
flap-splitting,  54. 
Gilliam's,  109. 
Hegar's,  58. 

round  ligament  suspension,  108. 
ventro-suspension,  109. 
Operative     technique     in     abdominal 
operations,  252. 
anesthesia  in,  254. 
closure  of  abdominal   wound   in, 

256. 
drainage  in,  255. 
dressing  of  wound  in,  257. 
incision  in,  254. 
place  of  operation  in,  252. 
preparation  of  instruments  in,  253. 
preparation  of  patient  in,  252. 
position  of  patient  in,  254. 
in  vaginal  operations,  258. 
preparations  for,  258. 
Ovarian  adeno-cystomata,  227. 
Ovarian  carcinoma,  246. 

metastatic,  246. 
Ovarian  cysts,  227. 
adhesions  of,  259. 
carcinoma  in,  241. 
complications  of,  258. 
dermoid,  231. 
diagnosis  of,  234. 

differential,  from  ascites,  237. 
from  distended  bladder,  238. 
from  distended  intestines,  237. 
from  fat  abdominal  wall,  237. 
from  fibroids,  236. 
from  pregnancy,  235. 
from     tuberculous     peritonitis, 
238. 
glandular,  227. 
infection  of,  240. 
malignancy  in,  241. 
multilocular,  227. 
papillomatous,  229. 
pathology  of,  227. 
pedicle  of,  233. 
twisted,  238. 
prognosis  in,  242. 
rate  of  growth  of,  233. 
ruptures  of,  240. 


Ovarian  cysts,  sarcoma  in,  241. 

symptoms  of,  233. 

treatment  of,  242. 

unilocular,  227. 
Ovarian  fibroids,  245. 
Ovarian  papilloma,  234,  246. 
Ovarian  pregnancy,  211. 
Ovarian  sarcoma,  247. 
Ovarian  tumors,  solid,  245. 
Ovaries,  anatomy,  218. 

carcinoma  of,  246. 

cirrhosis  of,  13,  224. 

cystic,  222. 

cause    of    retrodisplacements    of 

uterus,  102. 
treatment  of,  223. 

hematoma  of,  223. 

hypertrophy  of,  171,  224. 

infection  of,  221. 

prolapsed,  224. 
symptoms  of,  225. 
treatment  of,  226. 

resection  of,  223,  224,  226. 

suspension  of,  226. 
Over-distention  of  bladder,  102. 
Ovulation,  cessation  of,  12. 

Pain  due  to  carcinoma  of  uterus,  153. 
to  cirrhosis  of  ovaries,  224. 
to  cystic  ovaries,  222. 
to  cystitis,  86. 
to  endocervicitis,  127. 
to  fibroids,  179. 
to  hematoma  of  ovaries,  223. 
to  inversion  of  uterus,  117. 
to  laceration  of  cervix,  121. 
to  pelvic  cellulitis,  208. 
to  prolapsed  ovaries,  225. 
to  prolapsed  urethra,  82. 
to  prolapsed  uterus,  113. 
to  ruptured  extrauterine  pregnane}', 

214,  215. 
to  salpingitis,  195. 
to  sarcoma,  163. 
to  subinvolution,  166. 
to  suburethral  abscess,  81. 
to  twisted  pedicle  of  ovarian  cyst, 

239. 


282 


INDEX 


Pain  due  to  urethral  caruncle,  76. 

to  varicocele  of  broad  ligament,  250. 

to  vesico-vaginal  fistula,  70. 
Palpation,  4: 
Papilloma,  of  Fallopian  tube,  207. 

ovarian,  234,  246. 
Parametritis,  208. 
Paravaginitis,  42. 
Parovarian  cysts,  248. 
Parovarium,  248. 
Pelvic  abscess,  208. 
Pelvic  cellulitis,  208. 
Pelvic  diaphragm,  48. 
Pelvic  floor,  anatomy  of,  48. 

cystocele  result  of  injury  to,  62. 

injury  to,  50. 
Percussion,  abdominal,  5. 
Perineum,  laceration  of,  49. 
classification  of,  49. 
immediate  repair  of,  52. 
late  repair  of,  53. 
prophylaxis  in,  51. 
repair  of  complete  tears  of,  59. 
Perioophoritis,  220. 
Pessaries,  106. 

action  of,  108. 

dangers  of,  108. 
Pfiiger's  tubules,  248. 
Phosphates,  secondary  to  vesico-vaginal 

fistula,  70. 
Pituitary  gland,  14. 
Polypus,    uterine,   differentiated   from 

inversion,  118. 
Position,   after  labor,   cause  of  retro- 
displacements  of  uterus,  102. 

post-operative,  268. 
Positions : 

first  dorsal,  9. 

knee-chest,  10. 

lithotomy,  9. 

second  dorsal,  9. 

Sims',  10. 

Trendelenburg,  9. 
Posterior  vaginal  section,  technique  of, 

259. 
Post-operative  complications,  264. 
Post-operative  treatment  in  abdominal 
operations,  268. 


Post-operative    treatment    in    vaginal 

operations,  270. 
Potassium  acetate  in  pruritus  vulvae, 
25. 
in  urethral  caruncle,  77. 
in  urethritis,  80. 
in  vesico-urethral  fissure,  84. 
in  vulvitis,  21. 
Pregnancy,  abdominal,  213. 
cause  of  varicocele  of  vulva,  27. 
differential  diagnosis   of,  from  ova- 
rian cysts,  235. 
extrauterine,  210. 
follicular  vaginitis  in,  40. 
gas  bacillus  infection  in,  41. 
relation  of  fibroids  to,  178. 
Procidentia  uteri,  111. 
Prolapse  of  uterus,  111. 
associated  lesions  in,  112. 
degrees  of,  111. 

differentiated  from  cystocele,  114. 
from  hypertrophied  cervix,  114. 
from  rectocele,  114. 
operation  for,  115. 
repair  of  cervix  in,  115. 
repair  of  pelvic  floor  in,  115. 
use  of  pessaries  in,  114. 
Prolapsed  ovaries.     See  Ovaries,  Pro- 
lapsed. 
Protargol,  use  of,  in  urethritis,  80. 
Pruritus  vulvae,  24. 

due  to  acrid  vaginal  discharge,  24. 
to  diabetic  urine,  24. 
to  follicular  vulvitis,  22. 
to  neurosis,  24. 
Pyometria  due  to  atresia  of  cervix,  131. 
Pyosalpinx,  192. 

Rapid  deliveries,  120. 

Rectocele,  61,  102. 

Recto-vaginal  fistula,  66. 

Relaxation  of  uterine  ligaments,  103. 

Repair  of  vaginal  outlet,  post-opera- 
tive treatment  of,  270. 

Retrodisplacements  of  uterus,  101. 
acquired,  101. 
adherent,  105. 
causes  of,  101. 


INDEX 


283 


Retrodisplacements    of     uterus,    con- 
genital, 101. 

instrumental  replacement  of,  107. 

manual  replacement  of,  107. 

non-adherent,  105. 

operations  for,  108,  109,  110. 

symptoms  of,  102. 
Round  ligament  suspension  of  uterus, 

108. 

Salines  in  salpingitis,  198. 

in  urethritis,  80. 
Salpingitis,  189. 

bacteria  in,  189. 

catarrhal,  191. 

diagnosis  of,  196. 

interstitial,  192. 

pathology  of,  190. 

prognosis  in,  198. 

purulent,  192. 

symptoms  of,  195. 

treatment  of,  198. 

tuberculous,  204. 

uterine  fibroids  complicating,  177. 

with  endometritis,  134. 
Sarcoma  of  Fallopian  tubes,  207. 

of  ovarian  cysts,  241. 

of  ovaries,  247. 

of  uterus,  162. 

of  vagina,  46. 
Shock,  post-operative,  264. 

ruptured     extrauterine     pregnancy 
causing,  214,  215. 
Silver  nitrate  in  chancroids,  27. 

in  cystitis,  87. 

in  follicular  vaginitis,  41. 

in  gonorrheal  vaginitis,  40. 

in  urethritis,  80. 

in  vaginitis  of  children,  43. 

in  vulvitis,  21,  22,  23. 
Sims'  position,  10. 
Sinus,  post-operative,  266. 
Sitz  bath  in  urethritis,  80. 
Skene's  glands,  78. 
Speculum,  7. 

Nott's,  7. 

Simon's,  8. 
Sphincter  ani,  repair  of,  60. 


Spirochete  pallida,  26. 
Stenosis  of  cervix,  30. 

of  vagina,  43. 
Sterility  due  to  anteflexion,  100. 

to  endocervicitis,  127. 

to  lacerated  cervix,  121. 

to  stenosis  of  cervix,  131. 
Stitch  infections,  266. 
Stitches,  removal  of,  269. 
Strepto-bacillus  of  Ducrey,  26. 
Streptococcus,  cause  of  paravaginitis,  42. 

of  pelvic  cellulitis,  208. 

of  phlegmonous  vulvitis,  22. 

of  vaginitis,  41. 
Stricture  of  urethra,  81. 
Stroma  cells,  changes  in,  126. 
Subinvolution,  166. 

cause  of  retrodisplacements,  102. 
Suburethral  abscess,  81. 
Superinvolution  of  uterus,  167. 
Syncytioma  malignum,  163. 

Tampons,  262. 

in  aphthous  vaginitis,  41. 

in  endocervicitis,  127. 

in  endometritis,  139. 

in  lacerated  cervix,  122. 

in  retrodisplacements  of  uterus,  106. 

in  pruritus  vulvae,  25. 

in  salpingitis,  198. 

in  subinvolution,  167. 
Tannic  acid  in  gonorrheal  vaginitis,  40. 

in  gonorrheal  vulvitis,  21. 
Tenaculum,  8. 

Tenderness    due    to    ruptured    extra- 
uterine pregnancy,  214. 
Tenesmus  of  bladder  due  to  cystitis,  86. 

to  ovarian  cyst,  233. 

to  vesico-urethral  fissure,  84. 
Time  in  bed,  270. 

Tobacco  infusion  in  pruritus  vulva?,  25. 
Toxemia  due  to  ovarian  cyst,  233. 
Treatment,  after,  268,  270. 

local,  261. 
Trendelenburg  position,  9. 
Tubal  abortion,  213. 
Tubal    pregnancy.      See    Extrauterine 

Pregnancy. 


284 


INDEX 


Tuberculous  endometritis,  139. 
Tuberculous     peritonitis,     differential 
diagnosis  of,  from  ovarian  cyst,  238. 
Tuberculous  salpingitis,  204. 
Tuberculous  vagina,  42. 
Tubes,  infection  of.    See  Salpingitis. 
Tubo-ovarian  abscess,  193. 
Tumors,  of  broad  ligament,  cystic,  248. 
solid,  249. 
of     Fallopian     tube,     extra-uterine 
pregnancy,  215. 
hydrosalpinx,  192. 
pyosalpinx,  192. 
solid,  207. 
tubo-ovarian,  193. 
of  ovary,  cystic.    See  Ovarian  Cysts. 
solid,  245. 

carcinoma,  246. 
fibroid,  245. 
papilloma,  246. 
sarcoma,  247. 
of  urethra,  caruncle,  76. 
prolapse,  82. 
suburethral  abscess,  81. 
urethrocele,  83. 
of  uterus,  adenoma,  140. 
carcinoma,  142. 
chorio-epithelioma,  163. 
fibroid,  168. 
pyometria,  131. 
sarcoma,  162. 
of  vagina,  cystic,  45. 

solid,  46. 
of  vulva,  condylomata,  33. 
elephantiasis,  30. 
epithelioma,  29. 
fibroid,  32. 
hematoma,  28. 
hydrocele,  32. 
varicocele,  27. 
palpation  of,  5. 
prolapse  of  uterus  due  to,  112. 

Ulcer,  chancroid,  26. 

epitheliomatous,  of  vulva,  29. 

in  bladder,  86. 

in  urethra,  79. 

of  tuberculous  vaginitis,  42. 


Ulcerations  cause  of  stenosis  of  vagina, 

44. 
Ureters,  avoiding,  184. 
displaced,  178. 
injured,  73. 

relation  of,  to  arteries,  96. 
repair  of,  74. 
Uretero- vaginal  fistula,  73. 
Urethra,     dilatation    of,     in    cystitis, 
87. 
diseases  of,  76. 
over-distention  of,  82. 
prolapse  of,  82. 
stricture  of,  81. 
swollen,  80. 
Urethral  caruncle,  76. 
Urethritis,  78. 
gonococci  in,  78. 
purulent  discharge  in,  80. 
Urethrocele,  83. 
Urotropin  in  cystitis,  87. 
Urination,  burning,  79. 

frequent,  due  to  cystitis,  86. 
to  fibroids,  179. 
to  parovarian  cyst,  248. 
to  prolapse  of  uterus,  113. 
to  retrodisplacements  of  uterus, 

103. 
to  vesico-urethral  fissure,  84. 
painful,  due  to  cystitis,  86. 
to  pelvic  cellulitis,  208. 
to  prolapse  of  urethra,  82. 
to  prolapse  of  uterus,  113. 
to  urethral  caruncle,  76. 
to  urethritis,  79. 
to  vesical  calculus,  89. 
to  vesico-urethral  fissure,  84. 
Urine,  condition  of,  in  cystitis,  87. 
decomposition  of,  70. 
diabetic,  in  catarrhal  vulvitis,  23. 

in  pruritus  vulvae,  24. 
examination  of,  9. 

incontinence   of,    due    to    over-dis- 
tention of  urethra,  82. 
to  uretero-vaginal  fistula,  73. 
to  vesico-uterine  fistula,  73. 
to  vesico-vaginai  fistula,  70. 
retention  of,  79,  83. 


INDEX 


285 


Uterine   displacements,    cause   of   en- 
dometritis, 134. 
Uterine  fibroids.    See  Fibroids. 
Uterine    hemorrhage    due    to    adcno- 
fibromyomata,  179. 
to  adenoma,  141. 
to  carcinoma  of  uterus,  16,  152. 
to  chorio-epithelioma,  17,  164. 
to  endometritis,  15,  138. 
to  erosion  of  cervix,  113. 
to  excessive  ovarian  secretion,  15. 
to  extrauterine  pregnancy,  16,  215. 
to  fibroids,  16,  178. 
to  hypertrophic  endometrium,  16, 

140. 
to  inversion  of  uterus,  1 17. 
to  laceration  of  cervix,  121. 
to  miscarriage,  incomplete,  16. 
to  mucous  polypi,  129. 
to   retrodisplacements   of   uterus, 

16,  104. 
to  salpingitis,  196. 
to  sarcoma,  163. 

to  tuberculous  endometritis,  139. 
to  varicocele  of  broad  ligament, 
250. 
Uterine  sound,  8. 
Uterine  supports,  failure  of,  as  a  cause 

of  prolapse,  111. 
Uterus,  adeno-carcinoma  of,  149. 
adeno-carcinoma  of  cervix  of,  147. 
anatomy  of,  90. 
anteflexion  of,  99. 
anteversion  of,  99. 
atrophy  of,  after  menopause,  13. 
bicornis,  97. 
blood  supply  of,  95. 
carcinoma  of,  142. 
course  of,  151. 
diagnosis  of,  153. 
etiology  of,  151. 
squamous  cell,  143. 
symptoms  of,  152. 
treatment,  154. 
palliative,  155. 
radical,  156. 
chorio-epithelioma  of,  163. 
displacements  of,  99. 


Uterus,  displacements  of,   due    to    fi- 
broids, 178. 

double,  97. 

endometrium  of,  91. 

fibroids  of.    See  Fibroids,  Uterine. 

inversion  of,  117. 
operation  for,  119. 

lateral  displacements  of,  116. 

ligaments  of,  98. 

lymphatics  of,  96. 

malformations  of,  96. 

muscular  layer  of,  90. 

normal  position  of,  97. 

prolapse  of,  111. 

retrodisplacements  of,  101. 

retroflexion  of,  101. 

retroversion  of,  101. 

sarcoma  of,  162. 

serous  coat  of,  90. 

subinvolution  of,  166. 

superinvolution  of,  167. 

unicornis,  97. 

upward  displacements  of,  117. 

Vagina,  anatomy  of,  38. 
atresia  of,  44. 
carcinoma  of,  46. 
chorio-epithelioma  of,  46. 
dilatation  of,  for  vaginismus,  47. 
double,  97. 
fibroids  of,  46. 
gas  bacillus  infection  of,  41. 
sarcoma  of,  46. 
stenosis  of,  43. 

streptococcus  infection  of,  41. 
tuberculosis  of,  42. 
Vaginal  celiotomy,  post-operative  treat- 
ment of,  271. 
Vaginal  cysts,  45. 

Vaginal   discharge,    cause  of  hyperes- 
thesia of  vulva,  25. 
of  pruritus  vulvae,  24. 
due  to  carcinoma  of  uterus,  153. 
to  endocervicitis,  127. 
to  follicular  vaginitis,  40. 
to  gonorrheal  vaginitis,  40. 
to  sarcoma,  163. 
to  tuberculous  vaginitis,  42. 


286 


INDEX 


Vaginal  discharge,  due  to  vaginitis  in 

children,  43. 
Vaginal  drainage  in  salpingitis,  200. 
Vaginal  epithelium,  thickened,  62. 
Vaginal  hysterectomy  for  carcinoma, 
157. 

for  fibroids,  183. 
Vaginal  myomectomy,  182. 
Vaginal     operation     for     extrauterine 

pregnancy,  217. 
Vaginal    plug,    use    of,  in   atresia    of 
vagina,  45. 
in  stenosis  of  vagina,  44. 
Vaginal  section,  anterior,  techinque  of, 
259. 

posterior,  technique  of,  259. 
Vaginal  touch,  6. 
Vaginismus,  47. 
Vaginitis,  39. 

adhesive,  42. 

aphthous,  41. 

diphtheritic,  41. 

follicular,  40. 

gonorrheal,  39. 

in  children,  43. 

phlegmonous,  42. 

senile,  42. 
Vaginitis  secondary  to  vesico-vaginal 

fistula,  70. 
Varicocele  of  broad  ligament,  250. 

of  vulva,  27. 
Venereal  warts,  33, 
Ventro-suspension,  109. 
Vesical  calculus,  88. 

due  to  foreign  body,  88. 

method  of  removal  of,  89. 
Vesical  sphincter,  82. 


Vesico-urethral  fissure,  84. 
Vesico-uterine  fistula,  72. 
Vesico-utero-vaginal  fistula,  72. 
Vesico-vaginal  fistula,  70. 

in  treatment  of  cystitis,  88. 
Vestibule,  19. 

Vomiting,  post-operative,  265. 
Vulva,  anatomy  of,  19. 

epithelioma  of,  29. 

hyperesthesia  of,  25. 

injuries  to,  34. 

sclerosis  of,  27. 
Vulvitis,  21. 

catarrhal,  23. 

diphtheritic,  23. 

follicular,  22. 

gonorrheal,  21. 

phlegmonous,  22. 

secondary  to  vesico-vaginal  fistula, 
70. 
Vulvo-vaginal  glands,  20. 

abscess  of,  35. 

infection  of,  35. 

retention  cyst  of,  36. 

Warts,  venereal,  33. 
Water,  use  of,  in  cystitis,  87. 

in  urethritis,  80. 
Weight  of  uterus,. cause  of  prolapse,lll. 
Wound,    abdominal.     See  Abdominal 
Wound. 

Zinc  sulphate  in  gonorrheal  vaginitis, 
40. 
in  gonorrheal  vulvitis,  21. 
in  pruritus  vulvae,  25. 
in  urethritis,  80. 


(1) 


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